GM Case
August 6, 2023
Case scenario
Im Sanjana MP , 3rd year bds student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patients centered online learning portfolio
Case history
A 19year old male , a college student
Cheif complaint:
Fever since 30days
Shortness of breath since 15 to 20days
Headache and lower backpain since 30days
Cold since 3months
History of present illness:
Patient was apparently asymptomatic 1month ago then he developed low grade , intermittent type of fever which aggrevated since 15days , mainly during the night time , temporarily relieved on medication not associated with cold and cough , burning micturition , rash on body associated with bodypains and headache , lower backache . SOB since 15days which is present even on rest, which aggravates after having food . Bloating is present , chest tightness is present .
History of past illness:
Hypertension-no
DM - no
CVA -no
CAD-no
TB -no
Asthma-no
Previous surgeries -no
Personal history:
Appetite-lost
Diet- mixed
Bowel- regular
Micturition - burning sensation
Known allergies -no
Addictions - alcohol occasionally
Family history:
Not significant
General examination:
Pallor-no
Icterus-no
Clubbing-no
Cyanosis-no
Lymphadenopathy-no
Pedal edema-no
Systemic examination :
Abdomen :
Shape of abdomen- scaphoid
Tenderness-no
Palpable mass-no
Hernial orifice-no
Free fluid-no
Liver-not palpable
Spleen- not palpable
Bowel sounds -no
Cardiovascular:
Thrills -no
Cardiac sounds-s1 s2 heard
Cardiac murmurs-no
Provisional diagnosis
Viral pyrexia.
