General medicine case history-2


This is an online elog book to discuss our patient de-identified health data shared after taking his/her /guardians signed informed consent.Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with coll
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:-













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