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










Consent :











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