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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