General medicine case-2
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A 27 year old female presented to the OPD with chief complaints of fever, severe and persistent weakness of the body since 5 days.
History of present illness
Patient was apparently asymptomatic 5 days back before standing illness. Then, the patient was presented to the casualty with the complaints of fever and severe weakness of the body since 5 days.
Initially the patient had fever 5 days back and had taken the normal medication for the same. Then the patient was normal for 2 days.
Then the fever has recurred which is persistent for 3 days in association with severe and persistent body pains and vomitings.
The patient even complains of redness and burning sensation at times in the upper and lower extremities of the body.
Past history
No history of DM/HTN/Epilepsy/TB/Thyroid disorders
The patient had not undergone any surgeries.
Personal history
Diet : mixed
Appetite : decreased
Bowel and bladder : normal
Sleep :adequate
Addictions:none
Family history
No history of DM/HTN/CVA/CAD/Asthma/thyroid disorders
No similar complaints in the family previously.
Treatment history
Not significant.
General examination
Patient is conscious, coherent and cooperative.
No pallor, no icterus,no cyanosis,no clubbing,no lymphadenopathy.
Vitals
Afebrile
Bp :110/70 mm hg
PR: 85bpm
Rr: 14 cpm
Spo2: 98%
Systemic examination:
CARDIOVASCULAR SYSTEM:
Inspection:
Chest wall is bilaterally symmetrical.
No precordial bulge
No visible pulsations, engorged veins, scars, sinuses
Palpation:
JVP: normal
Auscutation:
Normal with regular heartbeat
S1, S2 heard
No murmurs
RESPIRATORY SYSTEM-
Position of trachea: central
Normal Bilateral air entry
No AV sounds
PER ABDOMEN:
Normal. No mass is palpable.
No organomegaly
CENTRAL NERVOUS SYSTEM:
Patient is Conscious
Speech: normal
Reflexes: present
Investigations
On 21/08/21
Hemogram:
RBC:4.37 mil/cumm
WBC:3800 cells/cumm
PLATELETS:35000 lakhs/cumm
Hb: 12.4
Blood sugar random: 96mg/dl
Blood group:AB+
Serum electrolytes:
Na+:1.36 meq/dl
K+:3.8meq/dl
Cl-:94 meq/dl
Blood urea:15mg/dl
Serum creatinine:0.9mg/dl
LFT:
SGOT:1.30 IU/L
SGPT:61 IU/L
ALP:80 IU/L
ALBUMIN:3.5gm/dl
On 22 /08/21
Hemogram:
RBC:3.86 millions/cumm
WBC:3200 cells/cumm
PLATELETS:70,000 lakhs/cumm
Hb:10.9
On 23/09/21
PLATELETS:1.3 lakhs/cumm
On 24/08/21
PLATELETS:1.51 lakhs/cumm
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