45 year old female patient complains of fever
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome."
Chief complaint:
49 year old female patient came to casuality with chief complaint of fever since 8 days ,sob since 5days ,cough since3 days and decreased urine output since 1 day
History of present illness:
Patient was apparently asymptomatic 8 days back then she developed fever suddenly , intermittent and low grade fever .patient complaints of sob since 8 days and cough with sputum since 3days.
She had history of bipedal edema and facial puffiness .
History of covid vaccination 10 days back .
Past history:
She is a known case of hypertension since 1 1/2 year .
No history of diabetes mellitus ,asthama,TB.
No similar complaints in the past
Personal history:
Diet -vegetarian
Appetite -normal
Sleep -adequate
Bowel and bladder movements-regular
No addictions
Family History:
No relevant family history
Treatment history:
She had a tubectomy in the past
Menstrual history:
Menopause at 43 years .
GENERAL EXAMINATION:
Patient was conscious,coherent ,moderate built
Clubbing:
Pallor
No cyanosis And lymphadenopathy
Vitals:
Temperature- afebrile
RR-32cycles /min
PR-120beats /min
BP-110/70 mm Hg
Spo2-82%
GRBS-187mg%
SYSTEMIC EXAMINATION:
CVS :
No thrills
S1 ,S2 heard
No cardiac murmurs
RESPIRATORY SYSTEM:
Dyspnea -present
Wheeze -present
Position of trachea-central
Breath sounds -present
Crepts are present
ABDOMEN:
Shape of abdomen -scaphoid
Tenderness -absent
Palpable mass -absent
Hernial orifices -normal
No bruits
No free fluid
Liver -not palpable
CNS:
Level of consciousness-conscious
Speech -normal
No stiffness
No kerning's sign
INVESTIGATIONS:
Hemogram:
Hb -8.2gm /dl
Total count -13,300 cells /cumm
Neutrophils -95%
Lymphocytes -3%
Eosinophils-1 %
PCV-22.2vol %
MCV-75.3 fl
RBC count -2.95 millions /cu mm
Platelet count -3.41 lakhs /cu mm
TPR GRAPH:
ECG REPORT:
Comments
Post a Comment