30 year old female complaint of high grade fever

 Hi I  am D.Vasista Pranav a third semester medical student.This is an online e block to discuss our patients health data after taking her consent. This also reflects my patient centered online learning portfolio

Name-Suvarna of age 30,occupation agriculture has

CHIEF COMPLAINTS: 

High grade fever associated with chills and rigors lasted for 5 days

Generalised body pains and neck pain,pain in movement of eyes since 6days 

Generalised weakness since 5 days

History of present illness:

Patient was apparently asymptomatic week back then she developed high grade fever associated with chills and rigor which lasted for 5 days and also body pains

History of past illness:

NO History of TB

NO History of diabetes

No Hypertension 

PERSONAL HISTORY:

Appitite normal 

Micturition normal

 Bowels normal

FAMILY HISTORY:

Diabetes –No

Hypertension- NO

Heart disease- no

Stroke –No

PHYSICAL EXAMINATION:

GENERAL

NO PALLOR

 NO ICTERUS 

NO CYANOSIS

NO CLUBING OF FINGERS 

 NO LYMADENOPATHY

NO OEDEMA OF FEET

NO MALNUTRTION

 NO DEHYDRRATION 

VITALS:

Pulse rate : 100/min

BP: 110/90 mm/hg

SpO2: 99% At room air

Temperature: 98.1 degree Celsius 

SYSTEMIC EXAMINATION:

CVS 

No thrills

S1 S2 cardiac sound heard 

Cardiac murmurs- NO

RESPIRATORY SYSTEM

 Position of trachea – center

Breath sounds – Vesicular

ABDOMEN

Tenderness – Not

Palpable mass-no

CNS

Conscious and coherent 

Speech Normal 

Reflexes present

INVESTIGATIONS:

Comments

Post a Comment

Popular posts from this blog

35 year old male with non productive cough since 6 months

Image
  Hi, I am D.Vasista Pranav  5th semester medical student. This is an online e log of patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.This e-log also reflects my patient centered online learning portfolio   I have been given this case to solve in an attempt to understand the topic of  " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. A 35-year-old male presented with the chief complaints of episodic dry cough and noisy breathing since 7 months.  History of Presenting Illness: The patient was apparently asymptomatic 7 months ago when he first noti
Read more

63 year old male with Facial puffiness and aggravated Xerosis with itching since 2 months

Image
Hi, I am D.Vasista Pranav  5th semester medical student. This is an online e log of patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.This e-log also reflects my patient centered online learning portfolio. 63 yr old male from pedhevulapalli came to OPD 5 days ago with  c/o-swelling of face and legs since 1 month      Fever (on and off)since 2 months HOPI: Patient was apparently asymptomatic 2yrs back.Then he had an attack of left hemiparesis.First he developed stiffness in his left wrist and then he developed stiffness in his left hand and left leg he has no sensation in his left limb.He immediately reached out to the hospital in miryalaguda and treatment was given accordingly. From then he is on clopidogri
Read more

54 yr old male with complaints of fever and vomiting

Image
  Hi, I am D.Vasista Pranav  5th semester medical student. This is an online e log of patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.This e-log also reflects my patient centered online learning portfolio   I have been given this case to solve in an attempt to understand the topic of  " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan CHIEF COMPLAINTS: A 54 year old male, resident of Yadadri, came with complaints of: * Fever since 3am in the morning. * Vomiting since 3am in the morning. * Troat pain since 7am in the morning. HISTORY OF PRESENT ILLN
Read more