General Medicine
24,August, 2022
A 17 year old female with Dengue hemorrhagic fever
E LOG GENERAL MEDICINE
Hi, I pindi Gayatri, 3rd Sem Medical Student.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 patient's 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 the comment box is welcome.”
I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
CHIEF COMPLAINTS
A 17 year old female came to the casuality with the chief complaints of fever since 7 days,headache and cough on 22nd, August.
HISTORY OF PRESENT ILLNESS
She came to the hospital with the complaints of fever,headache, cough since 15 days.
Giddiness since yesterday.
She had low grade intermittent fever associated with chills relieved on taking medication.
Frontal headache since 15 days.
Dry cough associated with chest pain,took syrup since 5 days no fever.
They visited nearby hospital before for the same reason aday ago.
HISTORY OF PAST ILLNESS
Not a known case of hypertension, Diabetes, epilepsy, CAD,Asthma, Thyroid, etc.
TREATMENT/DRUG HISTORY
No Diabetes
No hypertension
No CAD
No Asthma
No Tuberculosis
No Antibiotics
No Hormones
No Chemo/Radiation
No Blood transfusion
No surgeries
PERSONAL HISTORY
Single
Occupation-inter finished
Diet-mixed
Appetite-normal
Bowels-irregular(weakly 4 times)
Micturition-normal
Habits/addictions - toddy-occasional.
FAMILY HISTORY
No Diabetes, hypertension, heart disease, stroke,cancers,TB,Asthma.
Family History - fever sister and neice.
MENSTRUAL HISTORY
Age of menarche-13
Menstrual cycle =duration of cycle/no.of days bleeding=30/6
LMP-10/8/22 associated with pain,
No clots.
GENERAL EXAMINATION
No pallor
No icterus
No cyanosis
No clubbing of fingers /toes
No lymphadenopathy
No oedema of feet
No malnutrition
dehydration is present
VITALS
Temperature-98.9°F
Pulse rate-105 bpm
Respiratory rate-36cpm
Blood pressure-130/60mmHg(left arm)
SpO2 at room air-99%/at RA litres of 02
GRBS-229 mg/dL
SYSTEMIC EXAMINATION
CVS
No thrills
S1S2 sounds heard (JVPT)
No cardiac murmurs
RESPIRATORY SYSTEM
Position of trachea-central
Vesicular breath sounds heard
Adventitous sounds -Crepts
Decreased heart sounds-right ISA,LAA
No dyspnea
No wheeze
ABDOMEN
Shape of the abdomen-scaphoid
No tenderness
No palpable masses
Normal hernial orifices
free fluid -mild
No bruits
Non palpable liver
Non Palpable spleen
Bowel sounds are heard
CNS
Level of consciousness-conscious/alert
Speech-normal
Signs of meningeal irritation
No stiffness of neck
Kerning's sign:negative
Sensory system, motor system, Cranial nerves are intact.
Glassgow scale-15/15
Reflexes
Biceps triceps supinator knee ankle
Right + + + + -
Left + + + + -
Plantars-flexor
Cerebral Signs
Finger nose In-coordination:No
Knee heel In-coordination :No
INVESTIGATIONS
On 22nd, August
Investigation result chart
TPR graphic sheet
