45/F with FEVER AND HYPOTENSION

Chief complaints: (7/10/22)

1)FEVER since 10 days

2) SOB,GIDDINESS since 3 days

3) VOMITINGS and LOOSE STOOLS since yesterday

HOPI:

Patient was apparently asymptotic 10days back from when she had fever which is associated with chills and rigors and with diurnal variation , increased during night and subsided by night and subsided by night , she had giddiness and SOB, (grade III) since 3 days and yesterday night went to a local doctor , he gave ORS from then she had vomitings, 1episode, food as it’s content , non projectile. She also had 4 episodes of loose stools ,since today today morning. No blood /mucus in stools . Patient also complains of cough since 3 days (dry)

PAST ILLNESS:

N/K/C/O HTN,DM,Epilepsy ,TB, CVA,CAD

PERSONAL HISTORY:

Married, Homemaker, has normal appetite, takes mixed diet and has regular bladder movements, having loose stools since mrng., she is an occasional alcoholic, stopped since 1year

GENERAL PHYSICAL EXAMINATION:

Patient came by walk to OPD

Conscious, Coherent, cooperative

Vitals :

On presentation: BP-50/40mmhg

SYSTEMIC EXAMINATION

RS: BAE+,wheeze + , Fine crepts ICA,IAA

CVS: S1s2+

P/A: soft , Non tender

CNS: NAD

Comments

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This is an online Blog book to discuss our patients deidentified health data shared after taking his/ her guardians to sign an informed consent Here we discuss our patient problems through a series of inputs from the available Global online community of experts with n aim to solve those patient clinical problems with the current best evidence-based input This Blog also reflects my patient-centred online learning portfolio. Your valuable input on the comment box is welcome I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competence in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan CHIEF COMPLAINTS Fever since 10days Dry cough since 10days Generalized weakness and bodypains since 10days Decreased appetite since 5 days Red colored urine since 5 days Vomiting on Day 4 of illness Pain abdomen since 2 days H

G.NehaReddy

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