A 65 yr old women came to hospital with fever

Hi I am, AnirudhManne (roll no:11), 3rd sem medical student. This is an online e-log book to discuss our patient's health data shared after taking his/her consent . This also reflects my patient centered care and online learning portfolio.

A 65year old women farmer by occupation came to the hospital with fever since 19th november.

Case sheet

History of present illness:

The patient was apparently asymptomatic 1week ago Then she developed fever associated with chills and rigors which was continous and associated with body pains and head ache.On the way to the hospital  she developed vomiting during her travel.The patient also complains of itching.Then on thursday morning(24/11/22) she developed severe pain in the back which was releived on medication.she had 1episode of vomiting on Friday morning.she had also undergone blood transfusion due to decreased platelets in her blood 

History of past illness

The patient is a known case of Hypertension since 3yrs

The patient is not a known case of asthma, diabetes melitus,epilepsy,tuberculosis 

Personal history:

Diet- mixed
Appetite- decreased
Sleep- adequate 
Bowel Movement’s:regular .
No addictions
No burning micturition

Family history 
No significant family history 

General examination;
Patient was conscious, coherent and cooperative 
Moderately built and nourished
No pallor
No icterus
No cyanosis
No clubbing of fingers
No generalised lymphadenopathy 
No Pedal oedema


 
Investigations











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