A 53 year old female presented with fever , abdominal pain and chest pain

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


28/07/2022

Blog by Janhavi Virani 
Roll no 58



A 53 year old female who is a resident on Narsampet and is a farmer by occupation presented with chief complaints of 

1. Fever since 4 days 
2. Pain abdomen since 4 days 
3. Chest pain since 4 days 


HOPI - 
Patient was apparently asymptomatic 4 days back  then she developed fever which was sudden in onset , intermittent  associated with chills , headache , weakness and body pains . 
No history of nausea, vomiting or rash 

Complains of abdominal pain since 4 days which is gradually progressive diffuse dull aching type not  associated with diarrhoea , dysuria or  vomiting   
Not associated with food intake 
She says she has gas problem . 

Chest pain since 4 days 
associated with shortness of breadth 



DAILY ROUTINE- 
Patient usually gets up at 5:00 am in the morning does her household chores takes her 1 st meal of the day at 10 am in the morning and goes to work by the same time to the farm . Then she comes back in the evening around 5 pm . She takes her dinner at 9 pm and sleeps around 10 in the night . 

4 days back she developed fever . She went to Nalgonda hospital but her fever did not subside . 


PAST HISTORY- 
No similar complaints in the past 
No history of Diabetes, Hypertension, Asthma, Epilepsy, CAD , or any thyroid abnormality . 


PERSONAL HISTORY- 
Diet - mixed 
Appetite- decreased 
B&B - burning micturition since 4 days 
Sleep - adequate 
Addictions- toddy occasionally 


FAMILY HISTORY - no significant family history 


GENERAL EXAMINATION- 
Pallor - present 
Icterus- absent 
Cyanosis - absent 
Clubbing- absent 
Lymphadenopathy- absent 
Edema- absent 







Vitals :- 
PR - 82 bpm 
RR - 18 cpm
BP - 120/80 mm of hg 
Temperature- 99 F 




SYSTEMIC EXAMINATION- 

Cardiovascular system  
JVP - not raised 
Visible pulsations: absent 
Apical impulse : left 5th intercostal space in midclavicular line.
Thrills -absent 
S1, S2 - heart sounds heard 
Pericardial rub - absent


Respiratory system:
Patient examined in sitting position
Inspection:-
oral cavity- Normal ,nose- normal ,pharynx-normal 
Shape of chest - normal
Chest movements : bilaterally symmetrically reduced
Trachea is central in position.
Palpation:-
All inspiratory findings are confirmed
Trachea central in position
Apical impulse in left 5th ICS, 
Chest movements bilaterally symmetrical 
AUSCULTATION 
BAE+,  NVBS

Abdomen examination:
INSPECTION
Shape : mild distended since 4 days 
Scar : LSCS 
Umbilicus:normal 
Movements :normal
Visible pulsations :absent
Skin or surface of the abdomen : normal 
PALPATION 
Tenderness: presented in all 4 quadrants days 
PERCUSSION- tympanic
AUSCULTATION :bowel sounds heard



CNS : 
No focal neurological deficit’s 


PROVISIONAL DIAGNOSIS- 
Viral Pyrexia 
AKI 


INVESTIGATIONS- 
ECG - 


USG - gall bladder wall Edema 







TREATMENT- 




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