21 year old female patient

July 27 2022

A 21 year old female patient with fever, vomiting and generalised body pains

Hi, I am Gaddam shreya of 3rd semester .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 on that evening she started vomiting (non-bilious) with food as content which was associated with abdominal pain.

She had 6 episodes of vomiting.

Then patient presented to the casualty on 22nd of July where she was examined and was admitted for further treatment.

HISTORY OF PAST ILLNESS:

No history of similar complaints in the past.

Not a Known case of  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 of 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)

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

ECG

X-RAY:P-A VIEW

PALATE SHOWING PETECHIAE:

PROVISIONAL DIAGNOSIS:DENGUE FEVER

FOLLOW UP: On the evening of 27th of July, the platelet count of the patient went up from 36000 to 46000 cells per microlitre. There were no episodes of high fever since then.