A 55 year old woman came to casuality with chief complaints of fever, pain abdomen and abdominal distension

Hi, I'm Pantam Karthi vijayani, 3rd Sem 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 of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end.

CHIEF COMPLAINTS:
Fever since 15 days, pain in the abdomen since 2 days, distension of abdomen since 2 days. 

HOPI:  ( Presenting) 
Patient admitted on 12th of august with high fever and convulsions. Apparently, she developed pain in the abdomen since 2 days along with distension of abdome

HOPI: (Past) 
No significant past illness

Personal history:
She is married and a daily wage worker. 
Appetite
Bowel
Micturition
Addictions:  she is a regular consumer of alcohol since 15 years. 
Positive history of toddy intake and bettle nut intake. 
Family history:


PHYSICAL EXAMINATION:
General examination-
Pallor not seen
Icterus not seen
Cyanosis not seen
Clubbing not seen
Clubbing of fingers and toes- absent
Lymphadenopath- absent
Edema of feet is- present

Vitals:
Bp-
Pulse rate-90 beats per min
Respiratory rate-
Spo2-99
Temperature-99.1 degree fahrenheit

SYSTEMIC Examination:
. Cvs
No thrills
S1s2 heard
No cardiac murmurs

. Respiratory examination



.Abdominal examination

Shape of abdomen- obese
Palpable mass not seen

CNS -
She is conscious
Incoherent speech is seen
No neck stiffness
In Cranial nerves, motor system, sensory system no abnormal detected(NAD). 
INVESTIGATIONS:
ECG:

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