30 yrs old male with Fever and chills

 25th August,2023


Case scenario,
      Hi I'm Mogili Julia Spencer of 3rd bds here by making an elog book to discuss my patient health data, after taking his consent. This also reflects my patient centered online learning portfolio.

Case history: 
    Patient details: 
           A 30yr old male, resident of palle
Presented with the chief complaint of,
   Fever since 10 days
   Headache since 10 days
  Drowsiness since  a week

History of present illness: 
 Patient was apparently asymptomatic 10days ago and then developed fever of High grade type intermittent associated with chills and rigors and headache.
 known complaint of vomitings which are projectile in nature 

History of past illness: 
 Known case of seizures, involved in right upper limb , no loss of consciousness.
Not a known case of hypertension
Not a known case of tuberculosis
Not a known case of asthma
Not a known case of diabetes mellitus
Known case of epilepsy

Personal History: 
Occupation: shop keeper
Appetite: normal
Bowels: Normal
Micturition: normal
No known allergies
He is a teetotaller.

Family history: not significant

General examination: 
Built was normal
Patient was conscious coherent and co operative
No pallor
No icterus
No clubbing
No lymphadenopathy
No cyanosis
No edema

Vitals: 
Temperature: 98.8F
Pulse rate : 96 cpm
Respiratory rate: 18 cpm
Blood pressure: 120/80 mmHg

Systemic Examination:
CVS: no murmurs
       Cardiac sounds normal

Respiratory: position of trachea midline
                 Breath sounds vesicular
       
Abdomen: 
 Shape : scaphoid
 No tenderness
 Liver and spleen are not palpable 

CNS : no neck stiffness

Provisional Diagnosis: 
    Cerebral abscess.

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