A 40 year old female with viral fever
Hi, I am K. Komali , 3rd 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
CASE SHEET
CHIEF COMPLIANTS
A 40 year old female patient who was agriculturer by occupation and resident of Nalgonda came to OPD with the following symptoms :-
Fever since 4 days
Cough since 4 days
Nausea since 3 days
Loose stools from one day
Generalized weakness from one day
HISTORY OF PRESENT ILLNESS:
Patient had fever and generalized weakness on Sunday afternoon for which she had consultation at nearby local hospital. She was treated with intravenous fluids for having low blood pressure and then discharged later. Scanty, whitish, non blood stained cough since 4 days. History of nausea since 3 days for which she had decreased food intake. History of 4-5 episodes of loose stools that were non mucous, non blood stained, non foul smelling and not associated with abdominal pain for a day
HISTORY OF PAST ILLNESS:
No Diabetes mellitus
No hypertension
No Tuberculosis
No Coronary artery disease
No leprosy
No bronchial asthma
No epilepsy
FAMILY HISTORY:
No significant family history
ALLERGIES:
Allergic to dust
DRUG HISTORY:
No drug history
PERSONAL HISTORY:
Appetite : Normal
Diet : Mixed diet
Bowel movement : regular
Micturition : Burning micturition
Sleep : Normal
Addictions : None
MENSTRUAL HISTORY:
Age of menarche : 16 years
OBSTETRIC HISTORY:
Age at marriage : 14 years
Age at first child birth : 19 years
No. of children : 2 ( Cesarean section )
No abortions and still birth
SURGICAL HISTORY:
Total abdominal hysterectomy in 2012 due to multiple fibroids
PHYSICAL EXAMINATION:
A. General Examination
Conscious and coherent
Well built
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No pedal edema
Vitals:
Temperature : 98.4°F
Pulse rate : 94bpm
Respiratory rate : 18
Blood pressure : 110/70 mm of Hg
SpO2 : 98mm of Hg
FEVER CHART:
DIAGNOSIS:
Viral fever
