A 24 year old female resident of narketpally working as a computer operator came with the chief complaints of fits, vomiting,fever and head heaviness
24 April 2023
E LOG GENERAL MEDICINE
Hi, I am Naalla Gayathri , 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.
DATE OF ADMISSION:23 April 2023
CHIEF COMPLAINTS:
Patient complaints of fits, vomiting,fever and head heaviness yesterday i.e. on 23rd April 2023
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 day ago.
She had 3 episodes of seizures at around 6pm within the duration of 30 mins and with a gap of 10 minutes for each episode. She had mouth deviation and drooling of saliva is observed. 2nd episode is associated with vomiting.
She then had fever and experienced head heaviness.
She had 1 episode of vomiting at home and another in the hospital after admission which is non projectile, bilious and undigested food particles as content.
PAST HISTORY:
She had her first episode of seizure (first time) during her first pregnancy in the last trimester.
She got admitted into hospital due to delayed labour. Then she had increase in BP and then seizure occured in the hospital( eclampsia).
She is using a drug for seizures (levetiracetam) since 8 months.
No history of diabetes, asthma, tuberculosis, epilepsy, thyroid.
MENSTRUAL & OBSTETRIC HISTORY:
Menarche: 14 years of age
30/6 cycle
Uses 2 to 3 pads per day
She had 1 boy (elder) and a girl child.
Delivery is through c-section for both pregnancies.
PRESENT HISTORY:
Diet:mixed
Appetite: normal(decreased since fever and vomiting)
Sleep: adequate
Bowel: regular
Bladder: regular
Addictions:None
FAMILY HISTORY:
Maternal grandmother had hypertension.
ALLERGIEC HISTORY:
No known allergies.
GENERAL EXAMINATION:
Patient was conscious, coherent and cooperative.
Well oriented to time,place and person.
Moderately buit and nourished.
Pallor - absent.
Capillary refill time :Normal
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No edema
