Gm case

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.


Chief complaint:-
A 26 years old female presented with the chief complaints of 
- fever
- heavy menstrual bleeding

History of presenting illness:-
Patient was apparently  asymptomatic 5 days back then she developed fever which of is low grade not associated with chills and rigor , relieved on medication.2 days back she had her menstrual bleeding which is high for which he went to hospital and was given medication. When she went for follow up check up it is found that her platelet count is low and dengueNS1 is reactive.

History of past illness:-
 N/K/c/o :-Diabetes mellitus , hypertension,TB,asthma


Personal history:-
Diet:-mixed
Appetite:- normal
Bowel:- regular
Micturation:-normal
Addiction:-  no addictions 

Menstrual history:
Age of menarche: 12 years
-28 day cycle with 3 day menstrual bleed
-LMP: 1/9/22 

General examination:-
The patient is c/c/c and well oriented with time and place.

Vitals:-
Pulse rate:-  86 beats/min
Respiratory rate:-  14/min
Bp:- 110/70mmhg
Temperature:- 99 F


Physical examination:-
Pallor:-absent
Icterus:-absent
Cyanosis:-absent
Clubbing:-absent
Generalized lymphadenopathy:-absent
Oedema:-  no oedema 
Koilonychia :- not present

Systemic examination:-

Cvs
S1 s2 are heard with no murmers

Rs
BAE :- present
Vesicular breath sound are heard


Cns
Level of Conciousness : concious
Speech : normal
provisional diagnosis:-
Dengue with thrombocytopenia
Treatment:-
Iv fluid
Inj. Neomal 1gm/iv
Inj.pan 40mg iv/od
Inj.zofer 4mgiv/sos
Tab paracetamol 650mg/po/tid

Comments

Post a Comment

Popular posts from this blog

osce question

PREFINAL PRACTICAL EXAMINATION                           OSCE QUESTIONS  This is a case of 70 year old female who came with complaints of shortness of breath which were intermittent and increased since the last  25 days and after clinical examination was diagnosed with acute exacerbation of bronchial asthma. Sequence of events:- 👉What was your patient's hourly workflow before the illness and how did it change after?  Before the Illness: 1. Morning Routine: The patient used to.  Wake up at 6 AM  Engaged in household activities like dishwashing and cooking breakfast.  Breakfast comprised rice and curry, followed by cleaning the house and socializing with neighbors. 2. Daytime Activities:    Lunch around 1PM,  Having some sleep after lunch followed by cleaning and preparing food for son and daughter-in-law upon their return from work. Quality family time in the evening, dinner at 8 PM, and sound sleep by 9 or 10 PM. 3. Sleep Quality:    She used to have a peaceful sleep After the Ill
Read more

acute cholecystitis

Image
A 50 years old female occupation by daily labour resident of nalgonda. Chief complaints:-  pain in right abdomen since 2 days. History of presenting illness:- Patient   was apparently asymptomatic 2days back then he developed pain in right upper abdomen which is sudden in onset gradually progressive in nature. Pain is if pricking type radiating to back . Aggrvating factors:-  food consumption relieved on medication. Burning sensation in epigastric region. H/o fever since 2 days low grade intermittent associated with chills and rigors. No h/o vomiting,Loose stools, constipation, burning micturation. No loss of weight Past history:- H/o similar complaints one week ago Symptoms subsided on using medication. Not a know case of diabetes htn epilepsy tb asthma thyroid diseases. Personal history:- Diet:-mixed Appetite:-normal Sleep:-adequate Bowel and bladder :-regular Addiction:-no addictions Family history:- No relevent family history General examination:- Patient is conscious coherent coo
Read more

My experience in CBBLE

My experiences with general medicine in a case based blended learning ecosystem's CBBLE  Hello, This is R sumanth raj , a medical undergraduate studying in India. I'd like to share some of the interesting cases that helped me to learn more about medicine. NOTE : THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT. Alright let's get to the details of my first encounter with a patient. She was a 38 year old female came to casuality with chief complaints of fever and vomitings since 3 days. Link to the case:- case 1 This is my first encounter with the patient and i've learnt to communicate with the patient, to find out the relevant history that lead to
Read more