Give me a dummy case file for viral fever in a 37 years female in general medicine
Here is a dummy case file for viral fever in a 37-year-old female for general medicine:
CASE FILE - GENERAL MEDICINE
Hospital Name: City General Hospital
Department: General Medicine
Ward: Female Medical Ward - Bed No. 12
Date of Admission: 11 July 2026
Case No.: GM/2026/0711/042
PATIENT IDENTIFICATION
| Field | Details |
|---|---|
| Name | Mrs. Priya Sharma |
| Age | 37 Years |
| Sex | Female |
| Occupation | School Teacher |
| Marital Status | Married |
| Address | 14, Green Park Colony, Sector 5 |
| Contact No. | 98XXXXXXXX |
| Informant | Self (reliable) |
| Date of Admission | 11/07/2026 |
| Time of Admission | 10:30 AM |
| Referred by | OPD / Self |
CHIEF COMPLAINTS
- High-grade fever - 4 days
- Headache and bodyache - 4 days
- Generalized weakness and fatigue - 4 days
- Loss of appetite - 3 days
- Mild sore throat - 2 days
HISTORY OF PRESENT ILLNESS
Mrs. Priya Sharma, a 37-year-old female, presented to the General Medicine OPD with complaints of high-grade fever (measured at home as 102-103°F) for the past 4 days. The fever was sudden in onset, continuous in nature with occasional chills and rigors, partially relieved by antipyretics (Paracetamol 650 mg).
Associated symptoms include:
- Headache: Diffuse, throbbing in character, moderate in intensity (5/10 on pain scale), aggravated by bright light.
- Myalgia and Arthralgia: Generalized, involving bilateral lower limbs and back, no joint swelling or redness.
- Fatigue: Significant tiredness limiting daily activities.
- Anorexia: Poor appetite since onset, reduced oral intake.
- Sore throat: Mild, without difficulty swallowing.
- Mild dry cough: On and off, non-productive.
No history of:
- Rash or skin eruptions
- Vomiting or diarrhea
- Burning micturition
- Bleeding from any site
- Altered sensorium or seizures
- Chest pain or breathlessness
- Recent travel to endemic areas (malaria/dengue zones)
PAST MEDICAL HISTORY
| Condition | Details |
|---|---|
| Hypertension | No |
| Diabetes Mellitus | No |
| Tuberculosis | No |
| Asthma / COPD | No |
| Thyroid disorders | No |
| Previous hospitalizations | None significant |
| Previous surgeries | Appendectomy - 2015 (uneventful) |
| Previous similar illness | Mild viral fever ~2 years ago, managed conservatively |
DRUG HISTORY
- Paracetamol 650 mg SOS (self-medicated for 4 days)
- No regular medications
- Allergies: No known drug allergies (NKDA)
MENSTRUAL HISTORY
- Last Menstrual Period (LMP): 20 June 2026
- Cycle: Regular, 28-30 day cycle
- Duration: 4-5 days, normal flow
- No dysmenorrhea
- No intermenstrual bleeding
- Pregnancy status: Not pregnant (urine pregnancy test - negative on admission)
PERSONAL HISTORY
| Field | Details |
|---|---|
| Diet | Vegetarian |
| Appetite | Reduced (since illness) |
| Sleep | Disturbed due to fever |
| Bowel habits | Normal |
| Bladder habits | Normal |
| Smoking | Non-smoker |
| Alcohol | Non-consumer |
| Recreational drugs | Nil |
FAMILY HISTORY
- Husband and one child (age 10) at home - both apparently healthy
- No family history of tuberculosis, malignancy, or hereditary conditions
- No similar illness in family contacts currently
SOCIO-ECONOMIC HISTORY
- Middle-class family
- Lives in a semi-urban area
- Access to clean drinking water (municipal supply)
- No recent flooding or waterlogging in locality
- No contact with animals or birds
GENERAL PHYSICAL EXAMINATION
| Parameter | Finding |
|---|---|
| General appearance | Conscious, oriented, cooperative; looks ill and fatigued |
| Build | Average |
| Nutrition | Adequate |
| Temperature | 102.4°F (39.1°C) - axillary |
| Pulse rate | 98 bpm, regular, good volume |
| Blood Pressure | 110/70 mmHg (right arm, supine) |
| Respiratory Rate | 18 breaths/min |
| SpO2 | 98% on room air |
| Weight | 58 kg |
| Height | 162 cm |
| BMI | 22.1 kg/m² |
Pallor: Mild
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Lymphadenopathy: Bilateral mild cervical lymphadenopathy (non-tender, mobile, ~1 cm)
Edema: Absent
Dehydration: Mild (dry lips, reduced skin turgor)
SYSTEMIC EXAMINATION
Cardiovascular System
- S1, S2 heard; no murmurs
- JVP not raised
Respiratory System
- Air entry bilateral, equal
- No added sounds (no wheeze/crepitations)
Per Abdomen
- Soft, non-tender
- No organomegaly (liver and spleen not palpable)
- Bowel sounds normal
Central Nervous System
- Conscious and oriented to time, place, and person
- No neck stiffness; Kernig's sign negative
- No focal neurological deficit
- Pupils: B/L equal and reactive to light
Throat Examination
- Mild pharyngeal congestion
- Tonsils: Not enlarged
- No exudates
PROVISIONAL DIAGNOSIS
Viral Fever (Acute Undifferentiated Fever - AUF)
Differential Diagnoses to rule out:
- Dengue fever
- Malaria (Plasmodium vivax)
- Enteric fever (Typhoid)
- Influenza A/B
- COVID-19
- Urinary Tract Infection (UTI) - less likely
INVESTIGATIONS ORDERED
Hematology
| Test | Result | Reference Range |
|---|---|---|
| Hemoglobin | 11.8 g/dL | 12-16 g/dL |
| Total WBC Count | 4,200 cells/µL | 4,000-11,000 cells/µL |
| Differential Count | N: 52%, L: 40%, E: 3%, M: 5% | - |
| Platelet Count | 1,85,000/µL | 1,50,000-4,00,000/µL |
| PCV/Hematocrit | 36% | 36-46% |
| ESR | 28 mm/hr | 0-20 mm/hr |
| Peripheral Smear | No malarial parasite seen; mild lymphocytosis | - |
Interpretation: Lymphocyte-predominant leucopenia - suggestive of viral etiology
Biochemistry
| Test | Result | Reference Range |
|---|---|---|
| Blood glucose (random) | 98 mg/dL | 70-140 mg/dL |
| Serum Creatinine | 0.9 mg/dL | 0.5-1.1 mg/dL |
| Blood Urea | 22 mg/dL | 15-45 mg/dL |
| Serum Sodium | 136 mEq/L | 135-145 mEq/L |
| Serum Potassium | 3.8 mEq/L | 3.5-5.0 mEq/L |
| SGOT (AST) | 42 U/L | 10-40 U/L |
| SGPT (ALT) | 38 U/L | 7-40 U/L |
| Total Bilirubin | 0.9 mg/dL | 0.2-1.2 mg/dL |
| Serum LDH | 280 U/L | 140-280 U/L |
| CRP (Quantitative) | 18 mg/L | < 5 mg/L |
Serology & Specific Tests
| Test | Result |
|---|---|
| Dengue NS1 Antigen | Negative |
| Dengue IgM / IgG | Negative |
| Malaria Rapid Antigen Test (RDT) | Negative |
| Widal Test | O: 1:40, H: 1:40 (non-significant) |
| COVID-19 RAT | Negative |
| Influenza A/B Rapid Antigen | Negative |
| Urine Routine & Microscopy | Within normal limits; no pus cells |
| Blood Culture | Sent (awaited at 48 hrs) |
FINAL DIAGNOSIS
Acute Viral Fever - Undifferentiated (likely upper respiratory tract viral infection)
Based on:
- Acute onset fever with myalgia, headache, pharyngeal congestion
- Lymphocyte-predominant leucopenia
- Elevated CRP (mild)
- Negative specific serology (dengue, malaria, typhoid, COVID, influenza)
- Self-limiting clinical course
TREATMENT PLAN
Non-Pharmacological
- Bed rest
- Oral hydration - 2-3 litres of fluid/day (ORS, coconut water, soups)
- Tepid sponging for fever relief
- Light, nutritious diet
- Isolation precautions (droplet) until fever-free for 24 hours
Pharmacological
| Drug | Dose | Route | Frequency | Duration |
|---|---|---|---|---|
| Paracetamol (Tablet) | 650 mg | Oral | TID / SOS (temp >100°F) | 5 days |
| ORS Sachet | 1 sachet in 1L water | Oral | As needed | Till hydrated |
| Tab. Cetirizine | 10 mg | Oral | OD (at night) | 3 days |
| Tab. Vitamin C | 500 mg | Oral | OD | 5 days |
| Throat Lozenges | 1 lozenge | Oral | QID | 3 days |
| IV Fluids (NS/RL) | 1000 mL | IV | 8 hrly | 24-48 hrs (if oral intake poor) |
Note: No antibiotics prescribed (viral etiology; no evidence of secondary bacterial infection). Review antibiotic need if blood culture returns positive or clinical deterioration occurs.
MONITORING PLAN
- Temperature chart every 4 hours
- Pulse, BP, RR, SpO2 - 4 hourly
- Fluid intake/output chart
- Repeat platelet count and CBC after 48 hours (to monitor for dengue if platelet trend drops)
- Watch for warning signs: rash, bleeding, altered consciousness, severe abdominal pain, persistent vomiting
PATIENT COUNSELLING
- Complete rest at home after discharge; avoid school/work for 5-7 days
- Adequate fluid and nutritional intake
- Return immediately if rash appears, bleeding occurs, persistent vomiting, or worsening fever
- Follow-up in OPD after 5 days or earlier if required
PROGNOSIS
- Good. Viral fevers are typically self-limiting, resolving within 5-7 days with supportive care.
- No complications anticipated at present.
TREATING PHYSICIAN
Dr. Ananya Mehta, MD (General Medicine)
Reg. No.: MCI/XXXX/2019
City General Hospital
Signature: _______________
Date: 11/07/2026
This is a dummy/simulated case file created for educational and training purposes only. All names, details, and data are fictitious.
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