A 24 year old married female resident of narketpally a computer operator came with chief complaints of fever, vomiting, fits and head heaviness

24 April, 2023

E LOG GENERAL MEDICINE 

Hi, I am Nandini, 5th 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:
Fits, fever, head heaviness, vomiting since 1 day and was admitted in casualty on 23rd April 2023

HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic one day ago. Had 3 episodes of seizures within half n hour and duration of each episode was 20 mine and 2nd episode is associated with vomiting and head heaviness , after vomiting she felt a feverish. 
Vomiting was non projectile and bilious with food particles. 
Seizures were reduce after catching some keys, iron rod. 

PAST HISTORY:
During her 1st pregnancy due to late term she had an episode of seizure due to increased bp. 
No history of tuberculosis, epilepsy,asthma,CAD.
2-LSCS(lower segment Ceasarian Section). 

Menustral history:
Menarch at 14 yrs
30/6 days cycle, 2-3 pads/day initially, 1 pad/day.
Obstetrics- 1st boy 6years
2nd girl 3 years 
Both were lscs. 

FAMILY HISTORY:
Maternal grandma has hypertension. 
No other history. 


PERSONAL HISTORY:
Diet: mixed        
 Appetite: normal
Bowels : regular 
Bladder: regular
Sleep : adequate
Addictions:None

ALLERGIC HISTORY:
No known allergies.

GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative.
Pallor is absent
Icterus is absent.
Clubbing fingers absent. 
Cyanosis absent. 
Lymphadenopathy absent. 
Edema absent. 




 VITALS:
Temperature: Afebrile 
PR: 76 bpm
RR: 
BP: 
   

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