General medicine E-log 1

Hi , I am Harsha Chandana ,3rd semester student.  This is an online elog book to discuss our patients health data after taking his consent.  This also reflects my patient centered online learning portfolio. 

A 26 year old woman with pyelonephritis 

A 26 year old house wife came to the OPD with the chief complaint of fever since 5 days. She was admitted 6 days ago.

History of presenting illness:

Patient has back pain since 15 days and fever not accompanied with cough or cold since 5 days before she was admitted.Upon taking blood tests it was found that her WBCs were higher than normal and she was asked to visit a doctor.
The patient had vomiting for 4 days and swelling in the face and abdomen for 2 days and also passed blood urine for 2days after admission.

Past history:

The patient underwent a heart surgery at the age of 10 and was asked to take Acetron 2mg everyday which she stopped taking after 2yrs but resumed 7 months ago.

Personal history:

No addictions 
Mixed diet 
Adequate sleep
Regular menses

Family history:

No history of diabetes, hypertension, cancers, heart diseases or asthma.

General examination:

Patient was conscious, cooperative and coherent.
Slight pallor, no icterus, no cyanosis, no clubbing or lymphadenopathy.

Physical examination:






Diagnosis:
Pyelonephritis.

Medication received:



Letter of consent:













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