19 year old with fever, headache, chills& rigors


Hello, I am Harika Madala, a 3rd sem medical student.
This is an online e-log book to discuss our patient's health data shared after taking her/his/guardian's consent. This also reflects patient centred care and online learning portfolio.

Chief complaints

A 19 year old male student who is a resident of Eduluru village presented to the OPD with chief complaints of

1.Fever since 4 days
2.Headache since 4 days
3.Generalised weakness 

History of Present illness 
The patient was apparently asymptomatic 5 days back. Then he developed fever which was high grade and associated with intermittent chills& rigors.
Headache in the frontal region 
No history of cough, cold, sore throat, nausea, vomitings.
No history of chest pain, palpitations, syncopal attacks
No history of burning micturition, hematuria, malena

Past history

No DM
No HTN
No TB
No Asthma
No Epilepsy
No CAD

Personal history

Normal appetite 
Adequate sleep
Mixed diet
Regular bladder& bowel movements
Occasional drinker 

Family history 

Not significant 

Drug history

Not significant

Allergies

No known allergies

Addictions 

Occasional drinker 

General examination 

The patient is conscious, coherent, cooperative and well oriented
No pallor
No icterus
No cyanosis
No clubbing of fingers 
No lymphadenopathy 
No pedal edema

Vital signs

Temperature: 103 F
Pulse rate: 92/min
Respiration rate: 18/min
Blood Pressure: 120/80mm Hg
SPO2: 98%

Systemic examination 

CVS
S1& S2 heard

Investigations 

Hemogram
Complete Urine Examination 
Serum Electrolytes 
Blood Parasites 
ECG

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