GM-case2

August 23,2022
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:49 year old women with fever 

Chief complaints: complaint of fever since 10 days
Generalized weakness since10days
Nauseaand 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 uploa
d)

VITALS:
Temperature: 100.1°f

Pulse:_92__ beats per minute

Respiratory rate: _24__cycles per minute

Blood pressure: 130/80____ mm of Hg

SPO2: ___

SYSTEMIC EXAMINATION:

Cardiovascular system:

no thrills
nomurumurs
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:
chest X ray:
Pics upload
...

PROVISIONAL DIAGNOSIS: fever with thrombocytopenia 
_____________

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