GENERAL MEDICINE CASE 9
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45 years old female patient came to opd with chief complain of fever and shortness of breath
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 15days back and then she developed fever so she visited local hospital where she found out to be hypertensive and decresed blood count because of this she experiencing generalized weakness and body pains ,then later when she is also experiencing shortness of breath for which she visited to kamineni.
PAST HISTORY
No history of DM,hypertension
No history of TB
She had to FTND delivery
Regural mensuration cycle
PERSONAL HISTORY
Takes mixed diet
Normal appetite
Adequate sleep
Regular bowel and bladder movements
Not an alcoholic and smoker
FAMILY HISTORY
No similar complains seen in the family members
TREATMENT HISTORY
She is not a know case of any drug allergy
GENERAL EXAMINATION
Patient is conscious ,coherent and cooperative
No pallor
No icterus
No clubbing
No lymphadenopathy
Vitals:
Temp-103 °f
Bp-100/80mmHg
PR-144BPM
RR-28CPM
SPO2-97%RA
GRBS-285mg/DL
SYSTEMIC EXAMINATION
CVS:S1S2+
RS:DYSPNEA GRADE4-GRADE3.
No wheeze
Trachea position-central
Vesicular breath sounds heard
PER ABDOMEN:
Shape-scaphoid
Bowel sounds heard
CNS:NAD
INVESTIGATION
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