GM Case History-2
B.Namratha
Roll no.19
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
Date of admission:15-08-2021
This is a case of 20 year old male who is a daily labourer by occupation presented with chief complaint of Fever and Headache since 3 days.
HISTORY OF PRESENT ILLNESS:
The patient was suffering from high grade fever since 14th of august and took general medication.There was no change in temperature after taking medication and then he was admitted in our hospital on 15th of august.
Patient was having high grade fever associated with chills and severe headache.The patient also complains about periodic headache claiming that the headache remains from 6:00AM to 12:00PM.
No h/o cough,cold
No h/o nausea,vomiting,diarrhoea
No h/o constipation
No h/o pedal edema,facial puffiness
No h/o burning micturition
PAST HISTORY:
No h/o similar complaints in the past
Patient complains about headache
Not a known case of TB,DM,Asthma,Epilepsy
SURGERIES:
No h/o surgeries in the past.
PERSONAL HISTORY:
Diet:Mixed
Appetite:Normal
Bowel and bladder habits:Normal and regular
No smoking habits and takes alcohol occasionally.
FAMILY HISTORY:
Patient’s father suffers from diabetes.
No cancer deaths in the family.
TREATMENT HISTORY:
The patient is not allergic to any known drugs.
GENERAL EXAMINATION:
Patient was conscious,coherent,cooperative.
Patient looks thin built and is malnourished.
No pallor,icterus,Clubbing,Cyanosis,Lymphadenopathy.
VITALS:
Temperature:103
SpO2:99% at room air
Pulse rate:68bpm
Respiratory rate:18cycles/min
BP:90/60mm Hg
SYSTEMIC EXAMINATION:
CVS:
S1 and S2 heard
No murmurs.
RESPIRATORY SYSTEM:
Trachea is in central position.
Normal Vesicular breath sounds heard.
ABDOMEN:
Soft
No tenderness
No palpable mass
CNS:
Conscious and normal speech.
Normal gait
Cranial nerves normal
Sensory and motor system normal.
INVESTIGATIONS:
SARS COVID-NEGATIVE.
ECG:
FEVER CHART:
HEMOGRAM:
DENGUE ANTIGEN TEST:
ESR:
MALARIA PARASITE:
CUE:
SERUM PROTEIN:
SGPT:
SGOT:
SERUM BILIRUBIN:
SERUM CREATININE:
DIAGNOSIS:
DENGUE
TREATMENT:
Comments
Post a Comment