General medicine case - 6
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Chief complaint:
A 45 yr old female patient, came to the casualty with the chief complaint of fever , shortness of breath, cough and body pains, pain in the abdomen since 5 days.
History of present illness:
The patient was apparently asymptomatic before 5 days she then developed low grade fever associated chills and rigors, dry cough. No vomitings, no loose stools , no burning micturation. She developed SOB grade 3.
Past history:
No relevant past history.
Patient is not a known case of diabetes/hypertension/asthama/epilepsy.
Family history:
No relevant family history.
Personal history:
Diet: mixed
Appetite: inadequate
Sleep : inadequate
Pernicious habits: no such habits
General examination: patient is conscious, coherent, cooperative, well associated with time and place.
No pallor, cyanosis, clubbing.
Vitals:
Temp: 100F
Spo2: 96%
PR: 120bpm
RR: 30cpm
BP: 110/70mmhg
Fever chart:
Systemic examination:
CVS: S1 S2 heard, no murmurs
CNS : NAD
P/A : soft, non tender.
RS: BAE+,B/L IAA,IAM crepts.
Investigations:
Complete urine examination:
Albumin+
Ec: 2 to 3
Pc: 3-4
Bs: negative
Bp: negative
Sugar: negative
Blood urea: 90
Serum creatinine-1.1
Na+ : 139
K+: 4.8
Cl :95
Liver function test:
TB : 7.01
DB : 3.01
AST : 111
ALT : 75
ALP: 403
TP : 6.3
ALB : 2.0
ABG:
PH : 7.37
Pco2 : 53.3
Po2: 38.1
Hco3: 30.3
S.T Hco3: 26.7
Liver function test:
DB-3.10
TB-7.0
AST- 111
ALT:75
ALP-403
TP-6.3
ALB: 2.0
MP - negative
HIV- negative
HBSAG- negative
HCV- negative
Rapid dengue: negative
RTPCR: negative.
Provisional diagnosis:
Viral pyrexia with thrombocytopenia,viral pneumonia, sepsis with mods.
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