A 21 year old female patient with fever, vomiting and generalised body pains
Hi, I am G Sai Karthik, 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.
- * This is an ongoing case. I am in the process of updating and editing this ELOG as and when required
CHIEF COMPLAINT:
A 21 year old female patient who is a student came to the casualty on 22nd of July with complaints of high fever, vomitings and generalised body pains.
HISTORY OF PRESENT ILLNESS:
The patient was apparently asymptomatic 8 days ago. Then she developed high fever on morning of 21st July associated with chills and generalised body aches.Later that evening she started vomiting (non-bilious) with food as content which was associated with abdominal pain.She had 6 episodes of vomiting that evening.Then she presented to the casualty on 22nd of July where she was examined and admitted for further treatment.
HISTORY OF PAST ILLNESS:
No history of similar complaints in the past.
Not a K/C/O HTN/T2DM/ASTHMA/CAD/CVA/EPILEPSY/TYPHOID.
The patient has history of frequent headaches.
PERSONAL HISTORY:
DIET:Mixed
APETTITE:Lost
BOWEL AND BLADDER:Regular
SLEEP:Normal/Adequate
AlLERGIC HISTORY: Allergic to Brinjal, Roselle leaves and Potato
The patient has no history alcohol consumption, smoking of cigarettes and chewing of beetle nuts.
FAMILY HISTORY:
No significant family history.
GENERAL EXAMINATION:
The patient is moderately build and moderately nourished.
No pallor/No cyanosis/No clubbing of fingers/No lymphadenopathy/No icterus/No Oedema of feet
VITALS:
TEMPERATURE:Febrile(100 degree Fahrenheit)
PULSE RATE:88 bpm
BLOOD PRESSURE:110/70 mm Hg
SpO2:98%
GRBS:101mg/dL
SYSTEMIC EXAMINATION:
CVS:S1 S2 Heard,no murmurs
R/s:BAE+,Clear
CNS:Higher motor functions intact
P/A:Soft,Non tender,BS+
INVESTIGATIONS:
INVESTIGATION CHART
The investigation chart shows a reduction of platelet count.
USG ABDOMEN
FOLLOW UP: On the evening of 27th of July, the platelet count of the patient went up from 36000 to 46000 cells per microlitre. There were no episodes of high fever since then.
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