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

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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 

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











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