CASE 2: A 70yr old female with generalised pain and fever.

A 70 year old female with generalised body pains and fever.

Hi, I am P. Shreya Reddy , 3rd semester medical student.

This is an online elog book to discuss our patient's health data after taking his/her consent.This also reflects my patient centered online learning portfolio.

The patient’s consent was taken verbally prior to history taking and examination of her condition.

CHIEF COMPLAINT:

A 70 year old housewife from Yadadri district presents to the OPD with chief complaints of:
- Fever since 6 days ,
- Generalised weakness since 6 days,
- Pain in the both legs since 6 days and
- Vomitings the day before coming to the OPD

HISTORY OF PRESENT ILLNESS:

The patients was apparently asymptomatic 6 days ago.Then she developed mild leg pain associated with generalised weakness with fever. She later developed Shortness of breath which aggravated during her sleep and also complained of loss of appetite since the fever.
She had 3 episodes of non bilious and non projectile vomiting 5 days ago due to which her family bought her to the OPD the following day. 

HISTORY OF PAST ILLNESS:

No history of similar complaints in the past.
 K/c/o TYPE 2 DIABETES AND HYPERTENSION since the past 3 years for which she is on regular medication.

N/k/c/o Tuberculosis, Asthma, CAD, CVA and Epilepsy

PERSONAL HISTORY:
Married
Diet:Mixed
Apettite:Lost
Bowel and bldder:Regular
Sleep: Sleep disturbances due to body aches and shortness of breath.
Addictions: No history alcohol consumption, smoking of cigarettes and chewing of beetle nuts.

FAMILY HISTORY:

No significant family history.

GENERAL EXAMINATION:
The patient was conscious, coherent and Cooperative. She was well oriented to time palce and person
Moderately build and moderately nourished. 
No pallor
No cyanosis
No clubbing of fingers
No lymphadenopathy
No icterus
No Oedema of feet
VITALS:

Temperature:Febrile
BP:140/90mm Hg
HR:80/min
RR:18/min
SpO2:97%
GRBS:119 mg/dL 

SYSTEMIC EXAMINATION:

Cardiovascular System
-S1 S2 Heard
-no murmurs 
-no thrills

Respiratory system 
-no dyspnea
- no wheezing 
- trachea position: central
- breath sounds: vesicular

Central Nervous System 
- conscious 
- normal speech
- no neck stiffness
- no Kernig's sign
- cranial nerves: normal
- sensory : normal
- reflexes: present
- Higher motor functions intact

Abdomen 
- soft
- shape: scaphoid
- no tenderness
- no palpable mass
- no bruits
- liver: not palpable 
- spleen: not palpable
- genitals: normal
- speculum examination : normal
- P/R examination : normal

INVESTIGATIONS:

Blood picture showing: thrombocytopenia 

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