GM case-1



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:

Chief complaints:fever ,knee joint pain





HISTORY OF PRESENT ILLNESS:
Knee pains from past 3 years









ASSOCIATED DISEASES:

Diabetic , hypertension 



PAST HISTORY: knee joint pain from 2-3 years


PERSONAL HISTORY:
Diet: mixed
Married



FAMILY HISTORY:nil



DRUG HISTORY:
Took a injection at Yashoda 2 years ago


GENERAL EXAMINATION:


(Pic upload)

VITALS:
Temperature: normal

Pulse:70 beats per minute

Respiratory rate: 18cycles per minute

Blood pressure: 90/60 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:

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

Central Nervous System:

Conscious
Speech: normal

INVESTIGATIONS:
Biochemical investigations:
  


Microbiological investigations:
pathological investigations:




PROVISIONAL DIAGNOSIS:
Gout due to high blood urea level

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