An 18 year old male patient, student, presented with high grade fever and weakness since 2 days
E LOG GENERAL MEDICINE.
Hi, I am G Sai Karthik, 6th 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
CASE SHEET.
Chief complaints and duration.
An 18 year old male patient, student by occupation presented with high grade fever and weakness since 2 days.
History of present illness.
Patient was apparently asymptomatic 3 days back. He developed fever and weakness since 2 days.
Chest pain was present which was aggravated by deep breathing. Pain was sudden in onset, non progressive. No relieving factors.
He experienced sleeplessness last night.
Headache was present in the occipital and temporal regions since 1 day
History of loose stools since morning
History of past illness.
Patient is a known case of asthma since 3 years and is using medication.
No HTN
No DM
No TB
No CAD
No Syphilis
No CVA
Family history.
No significant family history
Allergies.
Patient is allergic to curd
Drug history.
Patient using inhalational formeterol and Budesonide since 3 days
Personal history..
Appetite is normal
Mixed diet
Loose stools since morning
bladder movement is regular.
Sleeplesness since 1 day
No addictions
PHYSICAL EXAMINATION.
A. General Examination
Conscious coherent and cooperative
Well built
No pallor
No Icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No oedema .
Vitals.
Temperature: 106 F
Pulse: 96
Respiration: 22/min
Blood pressure: 150/90 mmhg
Spo2: 96%
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