GENERAL MEDICINE ROLL NO 119

 Hi I  am Nikhil 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 year old female of occupation Dialysis 

Operator at Omni hospital came with

CHIEF COMPLAINTS: 

High grade fever associated with chills and rigors and body pains

History of present illness:

Patient was apparently 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 CLUBING OF FINGERS 

 NO LYMADENOPATHY

NO OEDEMA OF FEET

NO MALNUTRTION

 NO DEHYDRRATION 

VITALS:

Pulse rate : 86/mim

BP: 110/90 mm/hg

SpO2: 98% At room air

Temperature: 102 degree farenhiet

SYSTEMIC EXAMINATION:

CVS 

No thrills

S1 S2 cardiac sound heard 

Cardiac murmurs- NO

RESPIRATORY SYSTEM

 Position of trachea – center

Breath sounds – Vesicular

ABDOMEN

Gall bladder - edematous

Tenderness – Not

Palpable mass-no

CNS

Conscious and coherent 

Speech Normal 

Reflexes present

PROVISIONAL DIAGNOSES 

Thomboctopenia

INVESTIGATIONS         : 

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