GENERAL MEDICINE CASE

 B.VAISHNAVI

5th SEMESTER

ROLL NO. 22

This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

A 38 year old female came to the opd with chief complaints of fever since 2 months

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 2 months back, then she developed fever associated with chills, went to the local hospital, on medication symptoms relieved for 2 days and started again the next day. Associated with sweating. Had history of throat pain 10 days back, causing difficulty in Deglutition. H/o rash around the lips 10 days back. 

HISTORY OF PAST ILLNESS:

n/k/c/o DM, HTN, EPILEPSY, TB, ASTHMA

PERSONAL HISTORY:

Mixed diet

Sleep -adequate

Appetite- normal

Bowel & Bladder movements- regular

No addictions 

FAMILY HISTORY:

Not significant

GENERAL EXAMINATION:

patient is conscious, coherent, cooperative

Absence of pallor, icterus, cyanosis, lymphadenopathy, edema

VITALS

Temperature: Afebrile

Pulse rate:80/min

BP: 110/70 mm of hg

Respiratory rate :16/min

Spo2:98%at room air

GRBS:110 mg%

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

S1, S2 heard

Thrills absent

No murmurs

RESPIRATORY SYSTEM:

Normal vesicular breath sounds 

Trachea is in central position

No dyspnoea

No wheeze

ABDOMEN 

shape of abdomen- scaphoid

No tenderness

No palpable mass

Normal hernial orifices

No free fluid

No bruits

Liver and spleen are not palpable

Bowel sounds heard

CENTRAL NERVOUS SYSTEM

Patient is conscious

Speech-normal

No signs of meningeal irritation

Motor and sensory system is intact

PROVISIONAL DIAGNOSIS:

Pyrexia 

INVESTIGATIONS:

TREATMENT:

INJ MONOCEF 1 gm IV/BD

IVF-10 NS @ 50 ml/hr