GM case-7

August 26,2022
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:14 years male resident of narketpally with neck pain 

Chief complaints:
Neck pain on right side and difficulty in 
swallowing since 2 days.
Neck swellings and facial puffiness since 1 days.





HISTORY OF PRESENT ILLNESS:
Patient was apparently normal till November 2021 then he had high grade fever associated with chills diagnosed as dengue fever.
In March 2022, patient had similar episodes of neck swelling and difficulty in swallowing.
Since 2 days patient has neck pain on right side,difficulty in swallowing associated with neck swelling and facial puffiness 












ASSOCIATED DISEASES:
No H/o joint pains
No H/o SOB, palpitations
No H/o blurring of vision 





PAST HISTORY:
October 2021suffered with dengue fever



PERSONAL HISTORY:
Diet:mixed
Appetite:normal
Sleep:adequate 
Bowel:regular
Micturition:normal


FAMILY HISTORY:
Father had asthma 
Mother has allergy
Brother has similar neck pain associated with swelling 



DRUG HISTORY:



GENERAL EXAMINATION:
Pallor:no




VITALS:
Temperature: afebrile 

Pulse:84 beats per minute

Respiratory rate: 12 cycles per minute

Blood pressure: 120/70 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:

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:

 
 

Pathological investigation:
PROVISIONAL DIAGNOSIS:
Cervical lymphadenopathy 

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