GM Case-2

February 28

Hi, I am Patel Dinesh, 3rd BDS student.

This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio

        CASE HISTORY 

Patient Details:

A 70year old female patient presented with 

Chief complaints: fever,cold,cough,chest pain , shortness of breath 

History of present illness: 

Patient was apparently asymptomatic 15 days back 

Fever with high grade, intermittent not associated with chills and rigors ,cold from 3 days associated with dry cough with no sputum patient also had body pains ,no radiating chest pain,and had knee pain ,shortness of breath while walking and when fever is onset ,when the patient was suffering from fever she visited to hospital at nalgonda and she used medications but not relieved and after examining the blood samples she got to know that haemoglobin level was decreased 

Past History:

Hypertension since 30years

Diabetic since 10years 

She had gone through 3 surgeries  

1.Hysterectomy 30years ago 

2.hernia surgery 10 years ago

3.caesarean.

Patient is not a known case of thyroid disorder,asthma,tb 

Family history: Her brother is Diabetic 

Personal History 

Patient is conscious and cooperative.

Diet:mixed

Appetite: decreased from 15 days

Sleep: normal

Micturition : burning micturition

Bowel: regular.

Addiction:No addiction of Alochol and Smoking 


General examination:

Pallor : yes

Icterus: no

Lymphadenopathy:no

Clubbing: no

Malnutrition:no

Oedema of feet: yes 


Provisional diagnosis:

Suspected case of anemia.

Biochemical investigation: 


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