General medicine case presentation

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A 22 year old female came to OPD with complains of   fever since 10 days and rashes over body with itching sensation since 4 days.

History of present illness:

Patient was asymptomatic 1 month back ,she developed rash over the legs , hands and abdomen after coming contact with something in her family's lemon field for this she went to local doctor  who prescribed steroid ointment  and oral medication. She used it for 10 days .rashes are subside but rashes remains on the skin .  10 days ago ,then she developed fever associated with chills and body pains and vomitings 2 to 3 episodes per day then she diagnosed as  fever jaundice and typhoidfor that  she got treated. Symptomtically patient says that she took herbal medicationfor jaundice with complaints of fever on and off for 10 days andfollowed by 2 days vomitingsfollowed by developed rashes on the limbs   next day she developed oedema all over the body with decreased urine output and abdominal distension and history of cough and cold. 

Past medical history:

Patient has no history of Diabetesmellitus , Hypertension,Asthma,epilepsy .

Family history : 

no similar complications seen in family members.

Drug History : 

Patient is not allergic to any known drug.

Personal history:

Diet : Mixed

Sleep: Adequate

Apettite: normal

Bowel, bladder movements: regular

Habits: no addictions

General examination:

Pallor is present

Icterus is present

GeneralizedEdema seen all over the body

Rashes are seen allover the body

No history of cyanosis and clubbing

Vitals:

Temperature:  101 

Pulse rate 120 beats /min

Respiration rate : 18cpm

Blood pressure: 120/90 mmof hg

GRBS:86 mg / dl

Spo2: 99 in room air.

Systemic examination:

Cardiovascular system:

S1 S2 heard

No cardiac murmurs 

Respiration system:

Dysopnea: yes

Wheezing no

Trachea position : central

Breath sounds vesicular.

Abdomen :

Shape of abdomen schaphoid

Tenderness no 

Palpable mass no.

Hernial orifice normal 

Diffuse erythematous rash is seen allover the body on hands legs abdomen .

Central nervous system:

Patient is conscious ,coherent and cooperative to time and place.

Speech is normal .

Investigations:

1.USG abdomen: gall bladder edema , slight splenomegaly.

2. Serum electrolytes 

3.complete urine examination

4. Serum creatinine

5 . Liver function test : 

a.total bilirubin 10 mg / dl

6.complete blood picture

Final diagnosis:

Jaundice with hepatitis secondary to drug indused ( herbal medication).

Treatment:

1.inj.cephteioxone  1 mg IV bd 

2.inj.pantop 40 mg IV od

3.Tab dolo 500 mg tid orally

4. Tab .atarax 25 mg HS

5. Tab . Udiliv 300 g od 

6. Tab zincovit po od

7.lulifin cream bd L/A

8.moniter vitals and sos

9.temperture charting 4 th hourly.