GM case-5

August 21,2022
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:40 years male patient from velmakannane admitted at 9:30am in Kim's with fever 

Chief complaints:fever since 3 days, weakness since 5 days,nause and vomitting 





HISTORY OF PRESENT ILLNESS:
high grade intermittent fever associated with chills since 3 days, generalised weakness since 5 days,frontal headache,nause,stomach abset,no appetite, dry cough since 2 days








ASSOCIATED DISEASES:
Not associated with hypertension, diabetes 




PAST HISTORY:
He took medication for 2 days in local hospital for fever which was diagnosed as Typhoid.
He developed allergic reactions over hands and chest ,again medicated for this allergies reactions.
Right hand fracture 5 years ago 


PERSONAL HISTORY:
Married
Diet:mixed
Occupation: business
Micturition:normal
Bowels: regular 
Allergies:once developed due to medication 
 addictions :alcohol occasional 

FAMILY HISTORY:nil



DRUG HISTORY:




GENERAL EXAMINATION:
No pallor
No clubbings of fingers
No cyanosis
No icterus
No oedema of feet
No lymphadenopathy 
No dehydration 




VITALS:
Temperature: 99.6 F

Pulse:92 beats per minute

Respiratory rate:  18 cycles per minute

Blood pressure: 110/70 mm of Hg

SPO2: 98%
GRBS:116 mg%

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills 
No murumurs
Cardiac sounds: S1, S2 

Respiratory system:

No dyspnea
No wheezing
Breath sounds heard: vesicular

Abdomen:

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

Central Nervous System:

Conscious
Speech: normal

INVESTIGATIONS:
   
Microbiology investigations:
pathology investigations:

PROVISIONAL DIAGNOSIS:
Dengue with thrombocytopenia 

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