General Medicine E log 4
8 November 2022
A 70 year old female with generalised body pains and fever
Hi, I am Humera Firdous 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 70 year old housewife from Yadadri district presents to the OPD with chief complaints of fever , generalised weakness and pain in the legs since 6 days.She also complaints of vomitings the day before coming to the OPD
HISTORY OF PRESENT ILLNESS;
The patients was apparently asymptomatic 6 days ago.Then she developed mild leg pain associated with generalised weakness along with fever. She also developed Shortness of breath which was aggravating during her sleep.She also complained of loss of appetite since the fever.She had 3 episodes of non bilious and non projectile vomiting 5 days ago due to which her family rushed her to the OPD the next day.
HISTORY OF PAST ILLNESS:
No history of similar complaints in the past.
Known case of TYPE 2 DIABETES AND HYPERTENSION since the past 3 years for which she is on regular medication.
Not a known case of Tuberculosis/Asthma/CAD/CVA/Epilepsy
PERSONAL HISTORY:
DIET:Mixed
APETTITE:Lost
BOWEL AND BLADDER:Regular
SLEEP: Sleep disturbances due to body aches and shortness of breath.
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:
SYSTEMIC EXAMINATION:
CVS:S1 S2 Heard,no murmurs
R/s:BAE+,Clear
CNS:Higher motor functions intact
P/A:Soft,Non tender,BS+
INVESTIGATIONS:
Blood picture showing thrombocytopenia
DIAGNOSIS: Dengue fever
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