Case history -4
The case history is taken under the patients and her guardian consent .
A 29 year old female came to casualty with complaint of fever , cold , cough, weakness, dizziness , short of breath and sweating.
HISTORY OF PRESENT ILLNESS:
Patient was apparently well and asymptomatic 5 days back.
Patient complaints of fever, cold and generalised weakness from 5 days .
Patient complaints of dizziness from 4 days.
Patient complaints of shortness of breath and sweating from 2 days.
HISTORY OF PAST ILLNESS:
Patient complaints of having gall bladder stones 6years back and then underwent a surgery.
Patient complaints of detection of intramural fibroid at the posterior upper body and fundal region 4 months back under ultrasound.
Patients has grade one and grade two fatty liver
Under sonography , patient was detected with minimal free fluid in post operative delirium region which suggests pelvic inflammatory disease four months back.
No history of sore throat, constipation or loose stools and post vital bleeding.
PERSONAL HISTORY:
Appetite: normal.
Diet : mixed.
Bowel - bladder movement: regular
Micturition : normal.
Addictions : no addictions.
FAMILY HISTORY:
No history of diabetes, asthma, heart diseases, stroke in the family.
But patient compliant of hypertension to her father
TREATMENT HISTORY:
Patient complaints of taking metformin 500mg twice daily since 2 years.
MENSTRUAL HISTORY:
Age of menarche-12 years .
Menstrual cycle: normal with 30 days cycle with flow for 4 days .
Maternal status: patient was married at age of 14 and having 3 children with birth of first child being at 17 years.
GENERAL EXAMINATION:
Patient was coherent , cousiness and cooperative .
No pallor, cyanosis, icterus, clubbing .
No pedal edema.
No generalised lymphadenopathy.
VITAL SIGNS:
Temperature: 94.6degree F.
Pulse rate: 103/min.
Respiratory rate :38/ min.
SYSTEMIC EXAMINATION:
Cardiovascular system:
No thrills and cardiac mummers .
S1 and S2 are heard .
Respiratory system:
No wheezing and dyspnoea.
Postioning of trachea is central and breath sounds are vascular.
Abdomen:
Shape of abdomen: scaphoid .
No tenderness and no palpable mass is present.
No free fluid and bruits and liver and spleen are not palpable and bowel sounds are not heard .
Central nervous system:
Patient is conscious and speech is normal.No signs of meningeal irritation such as neck stiffness and kerning's sign.
Cerebral signs such as finger - nose in coordination and knee - heal incoordination are not present .
PROVISIONAL DIAGNOSIS:
Pyrexia under evaluation.
With Diabetes Mellitus type 2
Investigation :
ULTRASOUND REPORT:
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