40 yr old female admitted in the hospital
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40y old female came admitted in hospital
Chief complaints:
H/o fever since 4days which is of low grade intermittent with no chills &rigor
H/o of nausea since 3days
H/o of food intake since 3days
H/o of generalized weakness nd loose stools since a day
HOPI
Patient was apparently asymptomatic 5days back
On 4th low grade fever, generalized weakness associated with cough consulted local hospital for hypotension started on fluids and discharged.she had nausea which resulted on food intake, history of loose stool of 4to 5 episodes watery, foul smelling ,non mucoid ,non bloody not associated with abdominal pain
Cough since 4 days productive whitish ,scanty.
No myalgia,joint point , retro orbital pain ,chest pain ,or burning micturition.
HISTORY OF PAST ILLNESS:
N/k/o HTN,TB,epilepsy,asthma,thyroid.
H/o of dust allergy
TREATMENT HISTORY:
Nil
PERSONAL HISTORY:
Appetite: decreased
Diet:mixed
Bowel and bladder:regular
Sleep: adequate
FAMILY HISTORY:
Not significant
GENERAL EXAMINATION:
Patient is conscious and coherent
Moderately built and moderately nourished
Well oriented to time, place and person.
No pallor
No Icterus
No cyanosis
No clubbing
No lymphadenopathy
Oedema of feet -no
No malnutrition
No dehydration
VITALS:Temperature-101°f-no
No malnutrition
No dehydration
VITALS:Temperature-101°f
Pulse rate- 112/min
Respiratory rate- 16/min
BP- 100/70mmHg
SPO2 - 96%
CARDIOVASCULAR SYSTEM
Thrills: No
Cardiac sounds: S1 , S2
Cardiac murmurs: No
RESPIRATORY SYSTEM
BAE+
Dyspnoea:No
Wheeze: No
Position of trachea: Central
Breath sounds: Vesicular
ABDOMEN
Shape - Scaphoid
No tenderness, palpable mass,
No Fluid
No bruits
CENTRAL NERVOUS SYSTEM
Level of consciousness - consciouss
Speech - Normal
No signs of meningeal irritation
Cranial nerves - Normal
No motor or sensory deficit
Reflexes
Biceps Triceps Supinator Knee Ankle
Right + + + + +
Left + + + + +
INVESTIGATIONS
Viral pyrexia
