GM case 02: 49yr old woman with fever, nausea, myalgia, body pains
August 18,2022
Case scenario.......
Hi, I am Pranavi V , 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:
49 yr old woman with fever
Chief complaints: Fever since 7 days associated with nausea , body pains and myalgia
HISTORY OF PRESENT ILLNESS: Apparently the patient was asymptomatic 7 days ago but then had fever fir which she took antibiotics prescribed by local RMP. But due to persistent fever zhe 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:nil
PAST HISTORY: 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:
Occupation: Farmer
FAMILY HISTORY:nil.
DRUG HISTORY:
I.V. 75ml/hr
Inj neomol
Inj PIPTAL
Inj PAN 40mg
Inj Optineuron
T . Dolo 650mg
GENERAL EXAMINATION:
No pallor
VITALS:
Temperature: Afebrile
Pulse:___ beats per minute
Respiratory rate: ___cycles per minute
Blood pressure: ____ 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:
Malarial test :
Biochemical investigations:
Pathological investigations:
Blood investigations:
PROVISIONAL DIAGNOSIS: fever with thrombocytopenia
_____________
