40F with fever and body pains along with cough

40F with fever along with bodypains and cough

27 September 2023

Case of 40 yr old female with fever along with body pains and pain in the joints and cough

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 

A 40 yr old came to the opd with chief complaints of fever along with body pain and pain in the joints(dragging type) and cough since 2 days

HISTORY OF PRESENTING ILLNESS 

The patient was apparently asymptomatic 2 days ago and then she developed fever along with body pains and pain in the  joints and cough.

Which was relieved on taking medication 

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

PAST HISTORY 

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

Had undergone hysterectomy 3 years ago

FAMILY HISTORY 

No significant family history

PERSONAL HISTORY 

Appetite-->decreased 

Diet-->mixed

Sleep-->adequate 

Bowel movements---> regular 

GENERAL EXAMINATION

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

VITALS

PR: 75bpm

BP: 120/80mm hg

RR: 17 bpm

TEMPERATURE: 98.6F