GM -case 4

August 22,2022
Case scenario.......

Hi, I am P.sravani , 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:a 65 year old women fever with chills and rigors 

Chief complaints:Fever associated with chills and rigor since one week with high grade fever . 
Difficulty in walking since 3 days
Bilateral lower limb weakness 3 days
Diagnosed with Type 2 diabetes mellitus since 10 years 





HISTORY OF PRESENT ILLNESS:

Since one week she's having high grade fever with chills and rigors after that she complaint of decreased food intake and she missed OHAs since 2 days .c/o difficulty in walking and bilateral lower limb weakness.
C/o passage of urine and stools in clothes due to weakness in lower limbs since two days 









ASSOCIATED DISEASES:
Type 2 diabetes mellitus 
Hyperthyroidism





PAST HISTORY:Is a k/c/o diabetes mellitus on OHAs since 10 years 
K/c/o hyperthyroidism on T.neomercazole since 20 years 
Is not a k/c/o HTN/Asthma/CAD/Epilepsy 



PERSONAL HISTORY:nill



FAMILY HISTORY: nill



DRUG HISTORY:


GENERAL EXAMINATION:
Pallor : no
Icterus :no

Cyanosis : no

Clubbing : no

Lymphadenopathy : no


Edema : no


(Pic upload)

VITALS:
Temperature: 98.6°c/f

Pulse:_82__ beats per minute

Respiratory rate: __16_cycles per minute

Blood pressure: __120/80 mm of Hg

SPO2: __98%_

SYSTEMIC EXAMINATION:

Cardiovascular system:

No___ thrills
_no__murumurs
Cardiac sounds: S1, S2 ____

Respiratory system:

_no___ dyspnea
__no__ wheezing
Breath sounds heard: vesicular

Abdomen: scaphoid

Shape: distended
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard

Central Nervous System:

Conscious: normal 
Speech: _normal_____

INVESTIGATIONS:
Biochemical investigations:
Pics upload...

PROVISIONAL DIAGNOSIS:
___diabetic ketoacidosis__________

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