General medicine case 1
35 year old female complaints of fever
September 08, 2022
Hi,I am B Arundathi 3 rd semester student.This is an online elog book to discuss our patient health data after taking his consent.this also reflect my patient centered online learning portfolio.
CASE SHEET
Chief Complaints:
A 35 years old female patient farmer by occupation resident of miryalaguda came to op
Fever - 6 days
Lower abdomen pain - 6 days
Lower back pain - 6 days
Dry cough and sore throat
History of present illness:
Patient was apparently asymptomatic 6 months back.She developed joint pain after fever for which she was treated at private hospital at miryalaguda and now she came with complaint of fever which was peak in the evening rise of temperature and with chills and regors and also with lower abdomen pain and lower back pain.
History of past illness:
No diabetes
No hypertension
No CAD
No epilepsy
No asthma
No tuberculosis
She had undergone 3 caesareans
Drug history:
No drug history
History of allergy:
No history of allergy
Personal history:
Appetite - normal
Diet - mixed
Bowl movement - regular
Micturition - normal
Addiction: none
Drug history:
No drug history
History of allergy:
No history of allergy
Family history:
No family history
Physical examination:
Patient was conscious, coherent and cooperative.
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
Pedal edema present
Vitals:
Temperature : 97.6°F
Pulse rate : 78 bpm
Respiratory rate : 20 per minute
Blood pressure : 100/50 mm of Hg
sPO2 : 96%
GRBS-102mg%
Investigations:
Fever chart
ECG
