GM CASE
T.gowthami
Roll no:132(3rd sem)
Below is an E-log describing patient centered data approach and discussion regarding patient de- identified health data.
CASE (1)
HISTORY OF PRESENT ILLNESS:
✓ Patient was apparently symptomatic 3 days back.
✓He developed fever which is sudden in onset , continuous and not associated with chills and rigor.
✓No diurnal variations.
✓C/O loss of taste
✓No C/O cold,cough
✓No C/O abdominal pain,nausea,loose stools, vomitings.
✓No C/O burning micturition, decreased urine output, pedal edema,facial puffiness.
✓No C/O chest pain, palpitations, syncopal attacks .
✓No C/O SOB,orthopnea,PND.
HISTORY OF PAST ILLNESS:
✓Not a known case of HTN,DM,CAD,CVA
✓Not a known case of epilepsy,TB, asthma, Thyroid disorders.
PERSONAL HISTORY:
✓Diet-mixed
✓Appetite- decreased
✓Sleep-adequate
✓Bowel and bladder habits -regular.
✓Addictions-consumes toddy occasionally.
✓No drug allergies
FAMILY HISTORY:
✓No significant family history
GENERAL EXAMINATION:
✓Patient is conscious, coherent, co-operative.
✓Mild pallor
✓No icterus,cyanosis, clubbing,koilonychia, generalized lymadenopathy,edema.
VITALS:
✓Temperature-95.7°F
✓Pulse rate - 46 BPM
✓BP- 100/60 mmHg
✓Spo2 at room air-95 percent
✓GRBS-218 mg/dl
SYSTEMIC EXAMINATION:
Cardiovascular system:
S1,S2 heard
No murmurs
No thrills
Respiratory system:
Position of trachea-central
Bilateral air entry +
Normal vesicular breath sounds-heard
No added sounds.
Per abdomen:
Abdomen is soft and non tender
Hernial orifices-normal
No palpable masses
Bowel sounds heard
Central nervous system:
Speech-normal
No signs of meningeal irritation
Motor and sensory system-normal
Cranial nerves: intact
Reflexes : present
INVESTIGATIONS:
Complete blood picture:
Prothrombin time
Hemogram :
PROVISIONAL DIAGNOSIS:
Dengue fever with thrombocytopenia
TREATMENT GIVEN:
1)IV fluids
2)Tab.PCM 650mg PO/TID
3)inj.PCM 1g/iv/stat,if temperature is more than 101°F
4)inj.PAN 40mg iv/OD
5)inj.Optineuron 1 amp in 100ml NS/IV/BD.
DISCHARGE DETAILS:
✓The patient has reached his platelet count - 1.5 lakh
✓so,the patient has been discharged on 09/07/2021
TREATING FACULTY:
• Dr.Ajay (intern)
•Dr.C.V.Siddarth (intern)
•Dr.Dasari Siddarth (intern)
•Dr.Kusuma(intern)
•Dr.Pallavi (intern)
•Dr.Sameera (intern)
•Dr.Vinay (PG)
•Dr.Ashitha (PG)
•Dr.Vaishnavi (PG)
•Dr.Arjun (asst professor)
•Dr.Rakesh Biswas(H.O.D)
FINAL DIAGNOSIS:
Dengue fever with thrombocytopenia.
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