A 36 year old female has came to OPD with chief compliant with fever , chill since 8 days

 A 36  year old female has came to OPD with chief complaint with fever , chill since 8 days 


Hi, I am Nithin Maridi (roll no :82)3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.


CHEIF COMPLAINTS:

•SOB Since 5 days (12/8/22)   

•Fever with chills , headache , general body pains since 8 days (8/8/22) 


HISTORY OF PRESENT ILLNESS : 

Patient was apparently asymptomatic then she developed fever on 9/8/22 for which she went to a local hospital diagnosed as TYPHOID and UTI 


HISTORY OF PAST ILLNESS: 

H/O MASTECTOMY left ( 1 year back ) 

H/O RENAL CALCULI (1 year back ) 

N/k/c/o HTN DM THYROID CAD TB EPILEPSY


PERSONAL HISTORY:  

 Occupation : house wife 

Appetite : normal 

Diet : mixed 

Bowel : regular 

Micturation : Normal 

No allergies 

Addictions : Alcohol ( teetotaler ) 


FAMILY HISTORY: 

NIL SIGNIFICANT 


TREATMENT HISTORY : 

Blood transfusions 

Surgery - mastectomy 


GENERAL EXAMINATION: 

PALLOR : PRESENT 

Clubbing , cyanosis , icterus, edema, lymphadenopathy: ABSENT 


VITALS : 

TEMP : 102 F 

PULSE : 116 

BP : 100/70 

SPO2 : 98 

GRBS : 110

RESPIRATORY RATE : 26 CPM 


SYSTEMIC EXAMINATION: 

CVS : No thrills , no murmurs, S1 S2 present 


RESPIRATORY: No dyspnea, no wheezing , breath sounds - vesicular, trachea - central position 


ABDONEN : scaphoid shape , bowel sounds present , free fluid absent , liver and spleen non palpable 


CNS : pt is conscious, coherent , speech normal , all reflexes present 

 INVESTIGATIONS :





PROVISIONAL DIAGNOSIS :

TYPHOID 

TREATMENT :





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