CASE-1

Hi I  am Siddharth third semester medical student.This is an online e block to discuss our patients health data after taking her consent. This also reflects my patient centered online learning portfolio.

A patient of 25 years old female of occupation as Dialysis operator in OMNI Hospitals hyd came with complaints of  high grade fever and body pains .

CHIEF COMPLAINTS: 
High grade fever associated with chills and rigors and body pains
History of present illness:
Patient was apparently normal Before for 5 days then she developed high grade fever associated with chills and rigor with head ache since 5 days then she developed loose stools (black in colour ) since 2 days.
Which is semi solid in consistency and small volume with no foul smelling and not blood stained.
History of past illness:
NO History of TB
NO History of diabetes
No Hypertension 
PERSONAL HISTORY:
Appetite normal 
Micturition normal
Bowels irregular
FAMILY HISTORY:
Diabetes –No
Hypertension- NO
Heart disease- no
Stroke –No
PHYSICAL EXAMINATION:
GENERAL
NO PALLOR
NO ICTERUS 
NO CYANOSIS
NO CLUBBING OF FINGERS 
NO LYMPHADENOPATHY
NO OEDEMA OF FEET
NO MALNUTRITION
NO DEHYDRATION 
VITALS:
Pulse rate : 86/mim
BP: 110/90 mm/hg
SpO2: 98% At room air
Temperature: 102 degree Fahrenheit 
SYSTEMIC EXAMINATION:
CVS 
No thrills
S1 S2 cardiac sound heard 
Cardiac murmurs- NO
RESPIRATORY SYSTEM
Position of trachea – center
Breath sounds – Vesicular
ABDOMEN
Tenderness – No
Palpable mass-no
Gall bladder - appear oedematous
Moderately has ascites
CNS
Conscious and coherent 
Speech Normal 
Reflexes present
PROVISIONAL DIAGNOSES 
Thrombocytopenia
INVESTIGATIONS:

MEDICATIONS:

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