A 56 year old female patient,came to general medicine OPD with cheif complaints of fever since 10 days,burning micturation since am8 to 9 days and vomiting since 2 days.
Hi, I am G.Anisha 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.
A 56 year old female patient,who is agriculturer .Came to general medicine OPD with cheif complaints of fever since 10 days,burning micturation to 8 to 9 days,vomiting since 2 days.
HISTORY OF PRESENT ILLNESSES:
Patient was Apparently asymptomatic 10 days back then she had fever associated with chills,which intermittent in onset and rise in temperature at nights,followed by she had burning micturation since 8 days,2 episodes of vomiting (one is at night other at next day morning)since 2 days. History of regurgitation.
No history of abdominal pain,constipation heamaturia,shortness of breath,weight loss.
HISTORY OF PAST ILLNESS
No history of hypertension,Diabetes mellitus,TB,Asthma,Epilesy,coronary artery disease
DRUG HISTORY
No significant drug history
PERSONAL HISTORY
Loss of appetite since 10 days,
mixed diet
Bowel regular
Burning micturition since 10 days
No known allergies
Disturbed sleep since 10 days
Habits: Betel leaf occasionally and drinks white water occasionally
MENSTRUAL HISTORY:
Menopause attained at 47yeras
FAMILY HISTORY:
No significant family history
PHYSICAL EXAMINATION:
GENERAL EXAMINATION
Patient is conscious, coherent, comfortable and co-operative
Moderately built, moderately nourished
No pallor
No icterus
No cyanosis
No general lymphadenopathy
No clubbing of fingers
No Pedal edema
VITAL SIGNS-
Temperature: 101F
Pulse:90 bpm
BP: 130/100mm of hg
Respiratory rate: 14cpm
SpO2: 96percent
GRBS-112mg%
SYSTEMIC EXAMINATION
CVS:
Cardiac sounds: S1 and S2
No thrills
No cardiac murmurs
RESPIRATORY SYSTEM:
No dyspnea
No wheeze
Central location of trachea
Vesicular breath sounds
ABDOMEN-
Abdomen is scaphoid
Right hypochondrial and epigastric tenderness
No palpable mass
Non palpable liver and spleen
Bowel sounds are not heard
CENTRAL NERVOUS SYSTEM
Conscious
Speech- normal
Signs of meningeal irritation -
no neck stiffness
no kerming's sign
Cranial system - intact
Motor system - intact
Sensory system - intact
Cerebeilar signs
Finger nose- in coordination
Knee heel - in coordination
PROVISIONAL DIAGNOSIS
Fever, Urinary Tract Infection associated with gastritis .
INVESTIGATIONS:
ECG,CUV,HEMOGRAM,LFT,RFT,SERUM ELECTOLYTES,SMEAR FOR MALARIA,HIV ,HBS AB,HCV,BGT,BLOOD C/S,URINE C/S,USG-Abdomen and pelvis.
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