Gm case-1

 GM-case1


February 13,2023


Case scenario......


Hi, I am P.Minnu , 3rd year BDS 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:60year old women with fever


Chief complaints: complaint of fever since 5days and nausea and diarrhoea

Generalized weakness since 5days

Nausea and decreased appetite since 5 days

A 60 year female came to OPD complaint of high grade intermittent fever with chills relived on medication.History of generalized weakness since 5 days and nausea decreased appetite since 5 days and diarrhoea

History of abdominal discomfort as loose watery diarrhoea

No history of headache /cold/cough/chestpain


History of present illness

admitted for treatment


ASSOCIATED DISEASES:nill


PAST HISTORY:Normal fever



PERSONAL HISTORY

Nill



FAMILY HISTORY:


GENERAL EXAMINATION

No pallor

Cynosis :nill

Lymphadenopathy: nill

Malnutrition:nill

Dehydration:mil

Icterus:nill

Clubbing of finger:nill

Oedema of feet:nill



VITS

Temperature: 100.1°


Pulse:_82__beats per minutes


Respiratory rate: _24__cycles per minutes


Blood pressure: 130/80____ mm of 


SPO2: 



SYSTEMIC EXAMINATION


Cardiovascular systeem


no thris

nomurumurs

Cardiac sounds: S1, S2 


Respiratory systeem


no dyspnea

no wheezing

Breath sounds heard: vesicular


Abdomen: scaphoid

No tendernes

No palpable mass

Non palpable liver

No bruits

No Bowel sound


Central Nervous Systeem


Conscious:normal

Speech:normal


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