E-log 2. A 26 year old patient with Pyelonephritis
June-08-2022
Hi , I am Shreshta Reddy I, 3rd semester student. This is an online elog book to discuss our patients health data after taking her consent. This also reflects my patient centered online learning portfolio.
A 26 year old housewife,resident of Nalgonda was admitted into the hospital on Thursday ( Dt.02-06-22) with cheif complaints of back pain since 15 days and fever since 5 days.
HISTORY OF PRESENT ILLNESSES:
Patient was asymptomatic 6 days ago and then she suffered from fever. She consulted an rmp, was given some injections but the fever still persisted. When visited a local hospital she was said her wbc count is increased and was asked to consult a better doctor.
She passed red urine 6 days ago
Fever - since 5 days before admission
Chills, rigors
No cold , no cough
Swollen face from 2 days
No SOB
Vomitings : 4 days ago - 4 times (food)
PAST HISTORY:
Patient underwent a heart surgery at the age of 10.
She delivered an underweight baby (2kg 300g) 7 years ago (caesarean delivery)
Family history- Nil
Appetite- reduced since 6 days
Diet- mixed
Sleep- adequate ( disturbed sometimes because of the baby)
No addictions.
DRUG HISTORY:
Acetrom 2mg for heart problems since 10 years old. Discontinued after 2 years of usage. Restarted since 7 months ago.
GENERAL EXAMINATION :
Consious ,cooperative and coherent
Pallor- present
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No menstrual irregularities
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