117-gopi

A 30 year old female presented with fever and swelling of both the Limbs

           September06,2022 
                                                                                               Hi ,I am T Gopi(roll no 117) of 3rd sem medical student. this is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.
     

          
 CASE SHEET.      
   CHIEF COMPLIANTS:

A 30 year old female patient who was a farmer by occupation and resident of Miryalaguda came to OP
 Fever : 7 days
 Lower right abdominal pain : 7 days
 Lower back pain : 7 days
 Dry cough and sore throat : 2 days

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 6 months back. She developed joint pain following fever, for which she was treated in private hospital at Miryalaguda and now she came with compliants of fever which aggravated at evenings and also intermittent associated with chills and rigor. She complained of dizziness, headache, edema of both the limbs and pricking pain in the right lower abdomen.
She also has burning micturition since 7 days and dry cough.

HISTORY OF PAST ILLNESS:

No diabetes mellitus
No hypertension
No TB
No CAD
No leprosy
No bronchial asthma
No epilepsy
She underwent a C section surgery

FAMILY HISTORY:

No significant family history

ALLERGIES:

No allergies

DRUG HISTORY:

No drug history

PERSONAL HISTORY:

Appetite : Normal
Diet : Mixed diet
Bowel movement : Normal
Sleep : Inadequate
Addictions : None

PHYSICAL EXAMINATION:
A. General Examination

Conscious, coherent and coperative
Well built
No pallor 
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
Pedal edema present

Vitals:
Temperature : 97.2°F
Pulse rate : 88 bpm
Respiratory rate : 22 per minute 
Blood pressure : 90/60 mm of Hg
sPO2 : 96% 


INVESTIGATIONS:














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