A 27 yr old female with fever, productive cough
Hi, I am Shruthika 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.
pulse rate: 88bpm
The patient’s consent was taken verbally prior to history taking and examination of her condition.
CHIEF COMPLAINT:
A 23year female patient who is a worker came to the casualty on 15thof July with complaints of high fever with chills and productive cough. HISTORY OF PRESENT ILLNESS:
The patient had a fever spike so came for consultation.she again had a fever spike that is resolved spontaneous then she had no fever spikes. She underwent hemogram on 10 august no fever spike from 10 august.
HISTORY OF PAST ILLNESS:
No history of similar complaints in the past.
Not a K/C/O HTN/T2DM/ASTHMA/CAD/CVA/EPILEPSY/TYPHOID head ache occasionally that is relieved by medications
Tubectomy 3 months ago
Hypothyroidism during pregnancy. PERSONAL HISTORY:
DIET:Mixed
APETTITE:Normal
BOWEL AND BLADDER:Regular
SLEEP:Normal/Adequate
AlLERGIC HISTORY: No
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
blood pressure:110/70mm Hg
Spo2:98%
GRBS:101 mm/dL
INVESTIGATION:
The investigation chart shows a reduction in platelet count.
ECG
PROVISIONAL DIAGNOSIS: DENGUE FEVER