GM CASE 2
February 28
Hi, I am Karnati Tejaswini, 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
Patients details:
A 70 year old female resident of Narketpalli presented with
Chief complaints:
Fever ,
Chest pain,
Cold ,
Cough,
Shortness of breath
History of present illness:
Patient was suffering from intermittent fever which is high grade.
Fever associated with head ache and chest pain .
She has body pains and weakness .
Shortness of breath while walking and when fever is onset.
First the patient visited Nalgonda hospital but she was not relieved by the medication.
Patient admitted in this hospital with cold, cough and fever then after examining the blood samples she got to know that haemoglobin level decreased to 6 percent .
History of past illness:
She is Diabetic since 10 years.
Hypertension since 30 years
She had gone through 3 surgeries
1. Hysterectomy 30 years 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.
General examination:
Pallor : yes
Icterus: no
Lymphadenopathy:no
Clubbing: no
Malnutrition:no
Oedema of feet: yes
Provisional diagnosis:
Suspected case of anemia.
Q/A
Is blood transfusion is the only solution for this case?
Is intermittent fever is the only cause for this severe anaemia or is there any other reason?
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