GM -case 10


Hi , I am P.Aishwarya ,5th semester student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolios

55 F fever with since 10 days

A 55 yr F came to OPD with

C/C: fever since 10 days

HOPI:
the patient was apparently asymptomatic 10 days ago then she developed fever which was incidious in onset and gradually progressive, there are no aggrevating factors, relieved on taking medication 

Past history:
H/o taking medication - dolo 650( thrice a day)
- taxim( twice a day)

N/k/c/o DM, hypertension, asthama, TB, thyroid, epilepsy, CAD and CVA

Family history: insignificant

Personal history: 
Sleep- adequate
Appetite -reduced
Diet- mixed
Bowel and bladder - normal and regular
Addictions- No addictions

General examination: 
C/c/c
Moderately built and nourished
No signs of pallor,iceterus, cyanosis, clubbing, lymphadenopathy and pedal edema
no pallor 
no icterus 
lateral view of abdomen in comparison with bicep 
Vitals: 
PR - 80 cpm regular in rhythm and normal in volume
Bp- 110/70
Rr- 14 bpm
Temperature - febrile

Systemic examination:
Cvs- s1 S2 heard no murmurs
Rs- normal bronchial and vesicular sounds heard

Hemogram:

15/09/23


19/09/23

Rapid dengue test:

Strip test:

Treatment:
Temperature monitoring - 4th hourly
Healthy diet

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