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GM case-3


August 18,2022
Case scenario......

Hi, I am P.kathyayani, 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:
50 yr old female with fever

Chief complaints: Fever associated with chills since 7 days relieved on medication and nausea , body pains,myalgia, decreased appetite, generalised weakness,
 Upper abdominal discomfort as tightens. 



HISTORY OF PRESENT ILLNESS: Fever since 7 days took usual medication.
 She visted Mamatha hospital, Bhongiri and the tests confirmed thrombocytopenia
She visited Kims , Narketpalle on 15/08/22 and later got admitted on 18/08/22.





ASSOCIATED DISEASES:
No associated with headache, cough,cold,chest pain, hypertension, diabetes 





PAST HISTORY: Tubectomy done  in 1997.Uterine fibroids before 15years ago were treated with medication for about an year but showed poor prognosis leading her to get done a hysterectomy. 


PERSONAL HISTORY:
Diet:mixed
Married 
Occupation: farming
Appetite:lost
Bowel:regular
Micturition:normal
Allergies:no
Addictions:no




FAMILY HISTORY:nil.



DRUG HISTORY:



GENERAL EXAMINATION:
Pallor:no
Icterus:no
Lymphadenopathy:yes
Clubbing of fingers:no
Mild dehydration 
Enlarged tonsils 



VITALS:
Temperature: 100.1 F

Pulse: 92 beats per minute

Respiratory rate: 24 cycles per minute

Blood pressure: 130/80mm of Hg

SPO2: 99%

SYSTEMIC EXAMINATION:

Cardiovascular system:

thrills:no
murumurs:no
Cardiac sounds: S1, S2 

Respiratory system:

 dyspnea:no
wheezing:no
Breath sounds heard: vesicular

Abdomen:

Shape: scaphoid
No tenderness
No palpable mass
Non palpable liver
Palpable spleen:mild splenomegaly 
No bruits
Bowel sounds: heard

Central Nervous System:

Conscious 
Speech: normal

INVESTIGATIONS:

After medication painful blisters are seen on mouth
Biochemical investigations:
   



Pathological Investigations:


Microbiological investigations:

Blood investigations:


Dengue Test:

Chest X-ray:




PROVISIONAL DIAGNOSIS: Thrombocytopenia 

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