A 23 year female with fever and productive cough

Hi, I am P.Madhuri 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 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 (100degree)




Pulse rate:88 bpm

Blood pressure:110/70 mm Hg
SpO2:98%
GRBS:101mm/do
INVESTIGATION:

The investigation chart shows a reduction in platelet count
ECG

Provisional diagnosis:dengue fever 



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