29 year old female with URTI

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A 29 year old female, a resident of katangur , laborer by occupation presented to the department with chief complaints of fever and productive cough.

HOPI-  The patient had - productive cough since 10 days associated with cold and was not associated with throat pain. The patient came to the department on 12th December 2022 with the same complaints and was asked to get admitted after a chest X- ray and was prescribed some medications pertaining to the symptoms. But the patient did not get admitted and continued the medications for a week.Then she came to the department on 19th December 2022 with complaints of fever since 5 days and headache since 4 days and also complained that cough and cold did not completely subside.Fever was reducing after paracetemol admisnistration, but was again relapsing after a few hours.

PAST HISTORY- She complained of tingling sensation in hands and feet and dragging pain of legs since 1 month which used to occur once in 3 days.  She had undergone a hysterectomy 5 years ago. 

PERSONAL HISTORY- No history of diabetes, asthma, hypertension , thyroid, epilepsy. 

Mixed diet 

Sleep - adequate 

Appetite- decreased since 10 days 

Bowel and micturition - normal 

No addictions 

FAMILY HISTORY - NO significant family history.

H/O ALLERGIES - None 

GENERAL EXAMINATION- 

Conscious , coherent, cooperative 

Well oriented 

Moderately built 

Pallor not seen 

Icterus not seen 

Cynosis not seen 

No lymphadenopathy 

No clubbing of fingers

No pedal edema 

VITAL SIGNS - 

Pulse rate - 60 bpm

Respiratory rate - 14 cycles/ min 

Temperature non febrile 

RESPIRATORY SYSTEM EXAMINATION - 

INSPECTION - Trachea centrally placed 

PALPATION-  1.trachea centrally placed 

                         2. Vocal fremutus present 

AUSCULTATION - Chest was bilateral clear.

INVESTIGATIONS 





 

DIAGNOSIS - UPPER RESPIRATORY TRACT INFECTION .

THE PATIENT WAS DISCHARGED ON 21st DECEMBER. 



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