A 55 years old female presented with the yellowish discolouration of sclera amd a semiconscious state
E LOG GENERAL MEDICINE
Hi, I am G. Anisha , 3rd Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.
This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.
* This is an ongoing case. I am in the process of updating and editing this ELOG aChief complaints and duration.
Chief complaints :
A 55 year old female patient who was previously a agricultural labourer by profession came to the opd with the chief complaint of high fever associated with chills and voice drop in a semi conscious state.
History of present illness :
Patient was apparently asymptomatic 20 days back and then suddenly developed yellowish discolouration of sclera , skin and tongue.
She approached the hospital and was prescribed the medicines and went Back home.
She stopped the medication 4 days back.
On 18 July , she had high fever associated with chills. She was unconscious and was unable to speak.
History of past illness :
Diabetic since 5 years.
Hypertension since 5 years.
No TB
No CAD
No Syphilis
No Asthma
Family history :
No significant family history
Allergies :
No allergies
Drug history :
Medicines for hypertension and Diabetes
Personal history :
Patient was previously a farmer by occupation.
Appetite is normal
Mixed diet
Bowel movement is regular.
Bladder movement is regular.
Sleep was adequate.
Smoking stopped 6 years back because of diabetes.
Occasionally drinking.
She underwent hysterectomy 20 years back.
PHYSICAL EXAMINATION :
A. General Examination
Semi Conscious coherent and cooperative
Well built
Pallor is absent.
Icterus is present
No cyanosis
No clubbing of fingers
No lymphadenopathy
Vitals :
Temperature: 96.6 F
Pulse: 92
Respiration: 22/min
Blood pressure: 110/70 mmhg
Spo2: 90%
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