GM case
August 23,2022
Case scenario.......
Hi, I am P. Prajwala , 3rd sem medical 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.
CASE SHEET:49 year old women with fever
Chief complaints: complaint of fever since 10 days
Generalized weakness since10days
Nausea and decreased appetite since 10 days
A50 year female came to OPD complaint of high grade intermittent fever with chills relived on medication.history of generalized weakness since10days and nausea decreased appetite since 10 days.
History of abdominal discomfort as tightness since 15 days not an constipancy
No history of headache /cold/cough/chestpain
HISTORY OF PRESENT ILLNESS:She sought For consultation at local RMP and medication given. fever relived upon taking medication associated with excessive sweating .she had fever spikes since then used high end antibiotics.now admitted for further management and treatment
ASSOCIATED DISEASES:nil
PAST HISTORY:No comorbiditis.
Tubectomy
Hysterectomy done
PERSONAL HISTORY: nil
FAMILY HISTORY: nil
DRUG HISTORY:
GENERAL EXAMINATION:No pallor
Cynosis :no
Lymphadenopathy: present
Malnutrition:no
Dehydration:mild
Icterus:no
Clubbing of finger:no
Oedema of feet:no
(Pic upload)
VITALS:
Temperature: 100.1°f
Pulse:92 beats per minute
Respiratory rate: 24cycles per minute
Blood pressure: 130/80 mm of Hg
SPO2: ___
SYSTEMIC EXAMINATION:
Cardiovascular system:
No thrills
No murumurs
Cardiac sounds: S1, S2 ____
Respiratory system:
No dyspnea
No wheezing
Breath sounds heard: vesicular
Abdomen: scaphoid
No tenderness: upper abdominal tightness
No palpable mass
Non palpable liver
palpable spleen: mild splenomegaly
No bruits
Bowel sounds: heard
Central Nervous System:
Conscious: normal
Speech: normal
INVESTIGATIONS:
Biochemical investigations:
Pics upload...
chest X ray:
Pics upload
PROVISIONAL DIAGNOSIS: fever with thrombocytopenia
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