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General medicine case1


A 35 year old female complaints of fever

A 35 year old female with fever

September 14,2022


Hi,I am A.poojitha 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


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