General medicine case history-2

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ective current best evident based input.

Case:

18 yr old female,labourer by occupation ,was brought to the casualty with chief complaint of fever since 4 days, vomitings,and loose motions since 1day and shortness of breath since morning.

History of present illness:

Patient was asymptomatic 4 days back and then she developed fever, headache and shortness of breath,and loose motions.

Past history: no relavant past history, no known case of diabetes mellitus, hypertension.

Family history: no relavant family history.

Personal history:

Diet : mixed

Appetite :normal

Sleep: adequate

Bowel movement: irregular

General examination: 

On examination the patient was conscious, cooperative,coherent, and moderately built.

No pallor,cyanosis,clubbing,edema.

Vitals:

Temp :98.5F

Bp: 90/60 mmHg

PR:110bpm

RR:24 cpm

Grbs:119 gm/dp

Spo2 : 85% @RA

Cvs :

S1 S2 heard

P/A: soft, non tender

Provisional diagnosis: 

Viral pneumonia

Fever with multiorgan dysfunction

Investigations:-