Patient with fever, Decreased apetite and breathlessness

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CHIEF COMPLAINTS:

Pt complains of fever,decreased appetite since 1 month, Breathlessness since 1 week,vomitings and loose stools since 3 days. 

HOPI:

Patient was apparently asymptomatic 3 months back. Then she had multiple swellings in front of the left ear, for which she developed fever which was lowgrade, intermittent, no evening rise of temp, ass with decreased appetite since 1 month. She then had vomitings which was non bilious and non projectile, containing food particles. She had history of loose stools since 3 days, which is 4-5 episodes per day, watery in consistency. 

Past history:

K/c/o Hypertension since 7 years. 

7 yrs back she had c/o giddiness for which she went to hospital and was found to have HTN. 

Personal history:

Diet- mixed

Appetite-decreased

Bowel and Bladder movements- regular.


Addictions-


Allergies- none

General examination:


Patient is conscious, coherent and cooperative. Well oriented to time, place and person.

Moderately built and moderately nourished.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.

Vitals:



Temp- 98°F

BP-110/80MMHG

RR-18CPM

PR- 74BPM.

GRBS-92mg/dl on the day of admission. 

Spo2 - 100%


Systemic Examination:


CVS: S1,S2 Heard


      No Murmurs 




RS: B/L Normal Vesicular Breath Sounds Heard. 


On Inspection:


Shape - scaphoid


Umbilicus inverted


No scars and sinuses present. 


No visible pulsatios , no engorged veins


On palpation:


No rebound tenderness, no gaurding, no rigidity


No organonegaly


On percussion: 


No fluid thrill 


No shifting dullness


On Auscultation:


Bowel sounds heard



ACUTE VIRAL GASTROENTERITIS


K/C/O HTN SINCE 7YR


HIV POSITIVE (DENOVO DETECTED).







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