21 year female patient
A 21 year old female patient with fever, vomiting and generalised body pains
Hi, we are 3 semester students.This is an online E logbook to discuss our patient’s de-identified health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.
The patient’s consent was taken verbally prior to history taking and examination of her condition.
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.The patient had consumed outside food (Chicken and corn) on 20th of July.
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
