A 30 year old female with fever, body pains, neck pain, pain in movement of eyes, generalised weakness


Hello, I am Harika Madala, a 3rd sem medical student.
This is an online e-log book to discuss our patient's health data shared after taking her/his/guardian's consent. This also reflects patient centred care and online learning portfolio.

Chief complaints 

A 30 year old female, a daily wage worker, who is a resident of Imampalli village presented to the OPD with chief complaints of 
1. Fever associated with chills& rigors since 5 days
2. Body pains, neck pain since 6 days
3. Pain in movement of eyes since 6 days
4. Generalised weakness since 6 days

History of Present illness 

The patient was apparently asymptomatic a week back then she developed high grade fever associated with chills that lasted for 5 days and then the patient had developed generalised weakness, bosy pains, pain in movement of eyes 
No history of cold, cough, sore throat, nausea, vomitings 
No history of chest pain, palpitations, syncopal attacks
No history of burning micturition, hematuria, malena

Past history 

No DM
No HTN
No TB
No Asthma
No Epilepsy
No CAD
Hypothyroidism since 10 years

Personal history 

Decreased appetite 
Adequate sleep 
Mixed diet
Regular bladder and bowel movements 

Family history 

Not significant 

Drug history 

Not significant 

Allergies 

No known allergies 

Addictions 

No addictions 

General examination 

The patient is conscious, coherent, cooperative and well oriented 
No pallor 
No icterus
No cyanosis 
No clubbing of fingers 
No lymphadenopathy 
No pedal edema

Vital signs

Temperature: 98.1 F
Pulse rate: 100 beats/min
Respiration rate: 17 cycles/min
Blood Pressure: 110/90 mm Hg 
SPO2: 99

Systemic examination 

CVS
S1& S2 heard

Respiratory system
No dyspnoea
No wheezing 
Position of trachea- Central

ECG
















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