35 yr old female with fever along with body pains and chills

Case of 35 yr old female with fever along with body pains and chills

September 21,2023

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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. 

CHIEF COMPLAINTS 

 The patient came to the old with fever associated with pain in the backside of neck, along the spine and chills since 4 days

HISTORY OF PRESENTING ILLNESS 

The patient was apparently asymptomatic 4 days ago and  then she developed fever along with pain on the backside of the neck and chills since 4 days

 

The pain was sudden in onset and gradually progressing. 

 No C/O chest pain, orthopnea, PMD,decreased urine output, pedal edema or facial puffiness

PAST HISTORY

No significant past history 

Not a known case of hypertension, DM, CVA,CAD,TB, asthma

She had a C section 12 years ago

FAMILY HISTORY 

No significant family history 

PERSONAL HISTORY 

Appetite--> normal

Diet-->mixed

Bowel movements-->regular

Burning micturition 

GENERAL EXAMINATION 

No signs of pallor,icterus, cyanosis, clubbing, lymphadenopathy and pedal edema. 

VITALS

PR: 76 bpm

BP: 130/90mm hg

RR: 166 bpm

TEMPERATURE: 98.6F

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM:

S1 S2 heard

no murmurs

RESPIRATORY SYSTEM: 

No added sounds