A 21 year old pregnant women with 4days of fever chills and rigor
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
A 21 year old pregnant patient came to OPD with a cheif complaints of fever since 4 days
Associated with chills and rigor
HISTORY OF PRESENTING ILLNESS-
Patient was apparently asymptomatic 4 days back and then she developed fever which was sudden in onset and high grade.assosiated with chills and rigor.
Relieved on medication
No nausea and vomiting
No burning micturation
No cough /cold
No h/o rashes / bleeding manifestation.
PAST HISTORY-
No h/o diabetes
No h/o hypertension
No h/o TB
No h/o asthma
No h/o epilepsy
FAMILY HISTORY-
No relevant family history
PERSONAL HISTORY-
Diet - mixed
Appetite- normal
Sleep- adequate
Bowel and bladder- regular
Addictions - no addictions
General examination
Patient is conscious coherent and cooperative well oriented to time place and person.
No pallor
No icterus
No clubbing
No cyanosis
No lymphadenopathy
No edema
Temperature- afebrile
Pulse rate - 110 bpm
RR- 25
Bp- 110/70
Cardiac sounds- S1 and S2 present
Cardiac murmers- no
Respiratory system
Breath sounds- vesicular
Abdomen-
P/A - no tenderness
Provisional diagnosis -Viral pyrexia with thrombocytopenia
NS1 antigen positive.
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