30 year old female complaint of High grade fever

Hi I  am Panchakshar a third semester medical student.This is an online e block to discuss our patients health data after taking her consent. This also reflects my patient centered online learning portfolio

Name-Suvarna of age 30,occupation agriculture has

CHIEF COMPLAINTS: 

High grade fever associated with chills and rigors lasted for 5 days

Generalised body pains and neck pain,pain in movement of eyes since 6days 

Generalised weakness since 5 days

History of present illness:

Patient was apparently asymptomatic week back then she developed high grade fever associated with chills and rigor which lasted for 5 days and also body pains

History of past illness:

NO History of TB

NO History of diabetes

No Hypertension 

PERSONAL HISTORY:

Appitite normal 

Micturition normal

 Bowels normal

FAMILY HISTORY:

Diabetes –No

Hypertension- NO

Heart disease- no

Stroke –No

PHYSICAL EXAMINATION:

GENERAL

NO PALLOR

 NO ICTERUS 

NO CYANOSIS

NO CLUBING OF FINGERS 

 NO LYMADENOPATHY

NO OEDEMA OF FEET

NO MALNUTRTION

 NO DEHYDRRATION 

VITALS:

Pulse rate : 100/min

BP: 110/90 mm/hg

SpO2: 99% At room air

Temperature: 98.1 degree Celsius 

SYSTEMIC EXAMINATION:

CVS 

No thrills

S1 S2 cardiac sound heard 

Cardiac murmurs- NO

RESPIRATORY SYSTEM

 Position of trachea – center

Breath sounds – Vesicular

ABDOMEN

Tenderness – Not

Palpable mass-no

CNS

Conscious and coherent 

Speech Normal 

Reflexes present

INVESTIGATIONS: