A 24 year old female with seizures and fever
Hi, I am K.Hari chandana, a 3rd semester 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 ofcourse, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end.
HAPPY READING
CASE SHEET
CHIEF COMPLAINTS
A 24 year old female patient who is a computer operator by occupation and a resident of Shapally came to OPD with the following symptoms:-
Vomiting since 1 day
Fever since 1 day
Fits at around 7:30pm on 23/4/2023
Heaviness in the head after vomiting
HISTORY OF PRESENTING ILLNESS
The patient was apparently asymptomatic 1 day ago after which she experienced 3 episodes of seizures within intervals of 10 mins at around 6:00pm on 23/4 2023.
The total duration of seizures was around 30 mins in which all four limbs were involved and after which patient developed fever, heaviness in the head associated with dizziness and vomitings.
There were 2 episodes of vomitings one at home and the other after being admitted at the hospital which were non projectile and bilious with contents as food and no traces of blood.
PAST HISTORY
She had her first episode of seizure due to increase in blood pressure during her first pregnancy which was around 6 years ago.
She is not a known case of
Diabetes mellitus
Tuberculosis
Coronary artery disease
Bronchial asthma
FAMILY HISTORY
No significant family history
ALLERGIC HISTORY
No allergies
PERSONAL HISTORY
Appetite:- Normal
Diet:- Mixed
Bowel movement:- Regular
Micturition:- Normal
Sleep:- Adequate
Addictions:- None
MENSTRUAL HISTORY
Age of menarche:- 14 years
OBSTETRIC HISTORY
Age at first child birth:- 19 years
No.of children:- 2(Cesarean section)
No abortions and still birth
PHYSICAL EXAMINATION
General examination
Conscious and coherent
Moderately built and nourished
No pallor
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No pedal edema
Vitals:
Pulse rate: 76 beats/min