GM CASE

SUPRIYA GAGIREDDY 42

Hi,I am supriya 5th sem medical student.This is an online elog book to discuss our patients 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 problems with collective current best evidence based inputs.This E-log book reflects my patient centered online learning portfolia.

Case details:case of 38 year old female, resident of jajjireddy gudem, labourer by occupation, came to the OPD with chief complaints of:
-fever since 2months associated with chills. 
-Difficulty during Deglutition from 2days back. 

HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 2months back then intermittent fever started and relieved on medication. Temperature rise at evening at 4pm associated with chills. Rise of temperature for every 3days.

PAST HISTORY
Not a known case of Hypertension, diabetes mellitus, epilepsy, TB, CAD, asthma. 

PERSONAL HISTORY
Married
Occupation-labour
Appetite:normal
Non veg
Bowels:regular
Micturition:normal
No known Allergies
Addictions:Tea toddler
No other addictions

TREATMENT HISTORY
No treatment history

FAMILY HISTORY
No significant family history
PHYSICAL EXAMINATION
A. GENERAL EXAMINATION
Patient was conscious, coherent, co- operative. Well oriented to time, place and person.

 No pallor
No icterus
No clubbing
No cyanosis
No lymphadenopathy 
No edema
No malnutrition
No dehydration

VITALS
TEMPERATURE-Afebrile
BP-100/70mm of hg
PR-80 BPM, regular 
GRBS : 114 mg%
Spo2:98%
B. SYSTEMIC EXAMINATION
Patient was examined in a well lit room after taking the proper concern. 

CARDIOVASCULAR SYSTEM
S1, S2 +ve. 
No murmers

RESPIRATORY SYSTEM
BAE +ve
Normal vesicular breathe sounds heard

PER ABDOMEN
Soft, non tender, not palpable

CENTRAL NERVOUS SYSTEM
Conscious
Normal speech
No neck stiffness
No kernings sign
Cranial, motor, sensory systems :NAD

REFLEXES
Normal reflexes

INVESTIGATIONS
CBP:
Hb-9. 1g/dl
TLC-18, 700 Cells/cu.mm
Platelet count-3. 28/microliter.
CUE:
Blood urea:20mg/dl
Serum creatinine-0. 9mg/dl
Na+:135meq/l
K+:4.2meq/l
Cl-:101meq/l


LFT:
Total bilirubin:0.50mg/dl
Direct bilirubin:0.15mg/dl
SGOT:25IU/L
SGPT:19IU/L
Alkaline phosphatase:139IU/L
Total proteins:8.7g/dl
Albumin:3.5g/dl
A/G ratio:0.7
RBS
101mg%
PERIPHERAL SMEAR:
RBC:Normocytic normochromic
WBC:Increased smear
Platelet:adequate
TPR CHART

ECG
USG ABDOMEN
USG NECK

PROVISIONAL DIAGNOSIS
Viral fever with herpes labialis

TREATMENT
Inj. MONOCEF 1gm Iv bd
IVF -10NS @50 ml/hr with 1amp optineuron
Temp monitoring every 3hrs
Vitals monitoring every 4th hourly




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