A 21 year old pregnant women with 4days of fever chills and rigor

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.







This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.





I have 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 diagnosis and treatment plan.

A 21 year old pregnant patient came to OPD with a cheif complaints of fever since 4 days
Associated with chills and rigor

HISTORY OF PRESENTING ILLNESS-
Patient was apparently asymptomatic 4 days back and then she developed fever which was sudden in onset and high grade.assosiated with chills and rigor.
Relieved on medication
No nausea and vomiting
No burning micturation
No  cough /cold
No h/o rashes / bleeding manifestation.

PAST HISTORY- 
No h/o diabetes
No h/o hypertension
No h/o TB 
No h/o asthma
No h/o epilepsy

FAMILY HISTORY-
No relevant family history

PERSONAL HISTORY-
Diet - mixed
Appetite- normal
Sleep- adequate
Bowel and bladder- regular
Addictions - no addictions

General examination
Patient is conscious coherent and cooperative well oriented to time place and person.
No pallor
No icterus
No clubbing
No cyanosis
No lymphadenopathy
No edema

Temperature- afebrile 
Pulse rate - 110 bpm
RR- 25
Bp- 110/70
SpO2- 98%

SYSTEMIC EXAMINATION-
Cardiac sounds- S1 and S2 present
Cardiac murmers- no
Respiratory system
Breath sounds- vesicular 
Abdomen-
P/A - no tenderness
Provisional diagnosis -
Viral pyrexia with thrombocytopenia
NS1 antigen positive.

Comments

Post a Comment

Popular posts from this blog

INTERNSHIP LEARNING AND PROCEDURES PERFORMED

Image
  Anecdotal self reflections on their internship learning with some video  evidence of procedures performed  MY INTERNSHIP:-  Iam posted in medicine posting from 31 st july to 30 sept  Of this  ICU :- (1st august -6 th august)  Learned about VENTILATOR Assisted in 6 intubations  Done CPR TOOK SAMPLES  ABGs were taken by me  ABG sample from brachial artery                          Done procedure’s :- 4 ryles ; 5 foleys catheterisation  Learned how to use bipap machine   NEPHRO :- (7 th august - 12 th  august ) Learned about procedures like central line . Monitored patients in dialysis  Learned about the process of dialysis ; types of dialysis ;  Assisted in 4 central lines  Complications of dialysis  Done CPR.  WARD :-  Monitored patients in the nyt Took samples of FBS ; PLBS; HBA1C ; RFT ; LFT    Done IV canulation  PSYCHIATRY:- 15 August     to 1 st sept  MY PSYCHIATRY :-  I came across a patient , who was diagnosed with DISSOCIATIVE DISORDER. Diagnosis DISSOCIATIVE DISORDER Case Hist
Read more

Evidence based date wise workflow logs collated by the intern with clickable and verifiable link

Image
2) Evidence based date wise workflow logs collated by the intern with clickable and verifiable links As of 19/9/23 :-  CASE 1:- PaJR Group  https://chat.whatsapp.com/Jc43jR1klLF7ovLA3oagvU Blog :-  https://kattaphanikeerthanarollno72.blogspot.com/2023/09/a-70-year-old-male-presented-to-opd.html [05/09/23, 8:54:43 AM] ~ Keerthi Madireddi: @919381040824 update soap notes and also draw a graph showing the potassium values and intervention done. [05/09/23, 8:55:52 AM] Keerthana: Ok mam [05/09/23, 9:02:57 AM] ~ Keerthi Madireddi: @919381040824 please make me and hod sir as admin [05/09/23, 9:04:03 AM] ~ Keerthi Madireddi:  ☝🏻 [05/09/23, 9:46:51 AM] Rakesh Biswas Sir Hod Medicine: Mention duration in the title [05/09/23, 10:40:57 AM] Keerthana: Date-5/9/23 Ward-ICU    Bed 5  Unit 6  Date of admission 2/9/23 S -  C/o weakness in both upper and lower limb, C/o slurring of speech since 4 days  O -  On examination  Patient is conscious coherent and cooperative.  No Pallor, Icterus, cyanosis, cl
Read more

Self reflective writing on their medical student career 

Image
  Self reflective writing on their medical student career  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 patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information. This E blog also reflects my patient-centered online learning portfolio and your valuable input in the comment box is welcome. BLOG LINK :- https://kattaphanikeerthanarollno72.blogspot.com/2023/09/a-70-year-old-male-presented-to-opd.html It was my first Casuality duty day, I came across my 1 st case, A 70 year old was coming in a stretcher  with chief complaints of weakness in both upper limb and lower limb Since 1/2/23 evening  Slurring of speech since 1/2/23 evening. And I have no clue what to do  Then I decided to think what
Read more