final practical examination short case

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

 A 45yrs old female ,farmer by occupation , resident of nalgonda came to casuality with the Cheif complaints Of Fever and body pains, not associated with chills since 10days.

History of present illness:

Patient was apparently asymptomatic 10 days ago,then she developed fever which is sudden in onset and intermittent,not associated with chills and releived temporarily on medication.

She had an complain dark coloured stools since 3 days.(melena)

She also complains of body pains and joint pains since 2 days .

Also complains of vomitings 1 episode yesterday night which was non projectile and non bilious..There is also an history of loss of appetite since yesterday.

There is no history of rashes,burning,micturition, hematuria,hematemesis,neck stiffness.

History of past illness:

There are no similar complaints in the past.

Not a known case of TB, Asthma, Diabetes,HTN Epilepsy,CVA,CAD etc.

Personal history:

Diet-Mixed

Appetite- decreased since yesterday

Bowel and Bladder movements-Regular

Sleep- adequate

 No Addictions

Examination:

Patient was conscious, coherent, cooperative and well oriented to time place and person

Pallor- present

Icterus- absent

Cyanosis- absent

Clubbing- absent

Lymphadenopathy- absent

VITALS

Temperature- 101.4F

Pulse rate -80bpm

Resp rate - 16cpm

Blood pressure-110/82mmHg

sPo2 98% at room temperature

SYSTEMIC EXAMINATION

CVS: 

Inspection:

Chest wall is bilaterally symmetrical.

No precordial bulge is seen 

JVP- Normal

Palpation:

Apex beat -felt in the left 5th intercoastal space in the mid clavicular line 

Auscaltation:

S1&S2 are heard,no murmur found.

RESPIRATORY SYSTEM:

Position of trachea- central

Bilateral air entry, normal vesicular breath sounds are heard.

No added sounds

CNS:

Patient is conscious

Speech normal

No signs of meningeal irritation.

Motor and sensory system- Normal

Reflexes - 

Ankle-2+

Knee-2+

Bicep-2+

Tricep-2+

Supinator-2+

Cranial nerves - intact

PER ABDOMEN

Soft and Non tender.

PROVISIONAL DIAGNOSIS

VIRAL PYREXIA