55yrs female with fever , head ache and neck stiffness
Sahithi nalabolu
Hall ticket number:1701006124
Final exam long case:
Case presentation:
A 55yrs old female house maid by occupation came to the hospital on 9th june with
Chief complaints:
•Fever since 5days
•Headache since 5days
• neck stiffness since 4days
History of present illness:
Patient Was apparently asymptomatic 5days ago then she developed fever sudden in onset continuous type and relieved on medication associated with generalized body pains
Fever was not associated with chills and rigors.
Headache since 5days insidious in onset and throbbing type and progressive relieved on medication .
Neck stiffness since 4days.
History of vomiting 3days back 1episode non projectile non bilious content food particles.
No history of photophobia , seizures.
No history of cough , cold, loose stools , abdominal pain, sob
No history of burning of micturition.
Past history:
No history of similar complaints in past.
Not a known case of diabetes,Hypertension ,Asthma , tuberculosis, Thyroid.
Hysterectomy done 25yrs ago.
Family history:
No Similar complaints in family
No history of Dm , hypertension.
Personal history:
Diet: mixed
Appetite: decreased
Sleep: Adequate
Bowel and bladder: regular
No addictions and allergies.
General examination:
Patient is conscious coherent co operative well oriented to time, place ,person.
She is moderately built and well nourished.
No pallor,icterus, cyanosis, clubbing ,lymphadenopathy,edema.
Vitals:
Temperature:99°F
Bp:75bpm
PR:75bpm
RR:17cpm
Spo2:96%
Systemic Examination:-
CENTRAL NERVOUS SYSTEM EXAMINATION.
cranial nerves -
1-sense of smell - present
Motor system
Meninges :
Sensory system -
all sensations pain, touch, temperature, position, vibration sense are well appreciated .
Cerebellar signs:
Heel knee incoordination : no
Finger nose incordination: no
CARDIOVASCULAR SYSTEM
INSPECTION:
Chest wall - bilaterally symmetrical
No dilated veins, scars, sinuses
PALPATION:
•Apical impulse is felt on the left 5th intercostal space 1cm medial to mid clavicular line.
•No parasternal heave, thrills felt.
PERCUSSION:
Right and left heart borders are percussed.
AUSCULTATION:
•S1 and S2 heard , no added thrills and murmurs heard.
RESPIRATORY SYSTEM
INSPECTION:
Chest is bilaterally symmetrical
Trachea – midline in position.
Apical Impulse is not appreciated
Chest is moving normally with respiration.
No dilated veins, scars, sinuses.
PALPATION:
Trachea – midline in position.
Apical impulse is felt on the left 5th intercoastal space.
Chest is moving equally on respiration on both sides
Tactile Vocal fremitus - appreciated
PERCUSSION:
The following areas were percussed on either sides-
Supraclavicular- resonant
Infraclavicular- resonant
Mammary-resonant
Axillary-resonant
Infraaxillary-resonant
Suprascapular-resonant
Infrascapular-resonant
interscapular- Resonant
AUSCULTATION:
Normal vesicular breath sounds heard
No adventitious sounds heard.
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