A 30 year old female presented with fever and swelling of both limbs
Hi, I am K. Vaishnavi Reddy , 3rd Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.
This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING
CASE SHEET
CHIEF COMPLIANTS:
A 30 year old female patient who was a farmer by occupation and resident of Miryalaguda came to OP
Fever : 7 days
Lower right abdominal pain : 7 days
Lower back pain : 7 days
Dry cough and sore throat : 2 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 6 months back. She developed joint pain following fever, for which she was treated in private hospital at Miryalaguda and now she came with compliants of fever which aggravated at evenings and also intermittent associated with chills and rigor. She complained of dizziness, headache, edema of both the limbs and pricking pain in the right lower abdomen.
She also has burning micturition since 7 days and dry cough.
HISTORY OF PAST ILLNESS:
No diabetes mellitus
No hypertension
No TB
No CAD
No leprosy
No bronchial asthma
No epilepsy
She underwent a C section surgery
FAMILY HISTORY:
No significant family history
ALLERGIES:
No allergies
DRUG HISTORY:
No drug history
PERSONAL HISTORY:
Appetite : Normal
Diet : Mixed diet
Bowel movement : Normal
Sleep : Inadequate
Addictions : None
PHYSICAL EXAMINATION:
A. General Examination
Conscious, coherent and coperative
Well built
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
Pedal edema present
Vitals:
Temperature : 97.2°F
Pulse rate : 88 bpm
Respiratory rate : 22 per minute
Blood pressure : 90/60 mm of Hg
sPO2 : 96%
INVESTIGATIONS:
ECG:
Comments
Post a Comment