General medicine case 1
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A 48 year old male patient presented to the OPD with the chief complaint of fever and swelling in the right lower limb since 4 days.
History of present illness :
- Patient was apparently asymptomatic 4 days back then he noticed a swelling on the right lower leg due to trauma.
- The swelling is associated with pain, no discharge, no sinuses.
- It is associated with low grade fever and is intermittent.
- Fever is not associated with chills and rigors.
History of past illness :
- There is no history of diabetes, hypertension, asthma, tuberculosis, epilepsy
- There is no history of surgery
- The patient is a known case of filariasis of right leg 20 years ago.
Personal history :
- Patient has no loss of appetite
- He takes mixed diet
- His bowel and bladder movements are normal
- He has no habits of cigarette smoking / alcohol
- Low socio - economic status
Family history :
- No history of DM, hypertension, CAD, CVA or similar complaints in the family.
Treatment history :
-No treatment taken for present illness
- No history of drug allergy
General examination :
- Patient is conscious, coherent, and cooperative
- No pallor
- No icterus present
- No clubbing
- No cyanosis
- No generalised lymphadenopathy
- Pedal edema of right lower leg, non pitting type
Vitals : Temperature : 98.4 F
Pulse rate : 84 bpm
Respiratory rate : 24 cycles per minute
BP : 130/70 mm Hg
SpO2 : 98 %
Systemic examination :
Cardiovascular system
Inspection :
Chest wall is bilaterally symmetrical
No precordial bulge
No visible pulsations, engorged veins, scars, sinuses
Palpation :
JVP is normal
Ausculatation :
S1 and S2 heard
Respiratory system :
Position of trachea - central
Bilateral air entry is normal
Normal vesicular breath sounds heard
No added sound
PER abdomen :
Abdomen is not tender
Bowel sounds heard
No palpable mass or free fluid
Central nervous system :
Patient is conscious
Speech is present
Reflexes are normal
Provisional diagnosis :
Viral infection
Investigations :
08-08-2021
Hemogram -
M. P Strip test
Serum creatinine -
Blood urea -
Serum electrolytes -
Random blood sugar -
ECG -
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