Case history 4
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A 29 year old female patient came to the casuality with chief complaints of fever, cough since 5 days; generalized weakness since 5 days; dizziness since 4 days and shortness of breathe since 2 days.
History of present illness:
Patient was apparently asymptomatic since 5 days back then she developed fever which was insidious onset and continous.
Generalized weakness.
Cold was started just a day before fever which is sudden onset and there is nasal blockage.
Shortness of breathe since 2 days which is sudden onset which increased during walking, anxiety and reduced while taking rest.
Past history:
History of gall bladder stones 6 years back and cholecystectomy was done .
History of acidity problems since 2 years and using medications .
History of diabetes since 2 years and using metformin 500 mg bd.
Fatty liver.
4 months back in USG abdomen showed bulky uterus with intramural fibrinoid and minimal free fluid in pod region.
Treatment history:
Patient was on metformin 500mg since 2 years.
Cholecystectomy was done 6 years back.
No history of blood transfusion is mentioned.
Personal history:
Diet- Mixed.
Sleep-Adequate.
Bowel and bladder movements- Normal.
Appetite- Normal.
No history of allergies to known drugs.
No habits of drinking alcohol and smoking.
Family history:
No relevant history is seen in the family.
Menstrual history:
Age of menarche - 12 years.
Duration of cycle- 30 days.
General examination-
Patient was conscious, coherent and cooperative. Well oriented to time, place and person.
Moderately built and norished.
No pallor.
No icterus.
No cyanosis.
No clubbing of fingers.
No generalized lympadenopathy.
No edema.
Vitals:
Temperature- afebrile.
Pulse rate-103/ min.
Respiratory rate- 38 /min.
Blood pressure- 120/80
Spo2-98 %at room air.
Circulatory system:
Inspection-
Chest wall is bilateral symmetrical.
No visible pulsations, engorged veins, scars , sinuses.
No precodial bulge.
Palpation-
JVP is normal.
Auscultation-
S1 and S2 are heard.
Respiratory system-
Bilateral airway.
Position of trachea is central.
Normal vesicular breath sounds are heard.
No added sounds are heard.
Per abdomen:
Abdomen is soft and nontender.
Bowel movements are heard.
No palpable mass or fluid is found.
Central nervous system:
Patient is conscious.
Reflexes are normal.
Provisional diagnosis:
Viral pyrexia on evaluation.
Pelvic inflammatory disease??
Viral hepatitis- hepatitis B.
Investigations:
ULTRA SOUND REPORT-
SERUM CREATININE-
LIVER FUNCTION TESTS-
GLYCATED HAEMOGLOBIN-
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