case 2

February 28 2023

GM CASE 2
Monday

Case scenario.....

 I am G sai kaushik yadav, 3rd year 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 : A 29 year old female came with complaint of swelling of both  legs foot and vomitings and loose stools.


CHIEF COMPLAINTS :   hair loss since vomitings and swelling of legs  since 15 days, 

HISTORY OF PRESENT ILLNESS : 
Patient was apparently asymptomatic 1 week back, then he developed pain in both the upper and lower limbs and had shivers. The pain first developed in feet and progressed gradually after a day or 2. He's been taking treatment from 3 days. 

PAST ILLNESS :
No Hypertension, No Diabetes mellitus, no any other history.

PERSONAL HISTORY : 
Mixed diet.
Loss of apatite. Most of the time, he feels fullness of stomach.
Have proper sleep.
No bowel since 2 days.
Regular bladder movements.
Alcohol - occasionally 

FAMILY HISTORY : 
Diabetes : no
Hypertension : no

DRUG HISTORY 


GENERAL EXAMNLINATION : 
Built : well built
Nourishment : well nourished 
Consciousness: in Conscious
Pallor : pale pink 




Icterus : pale pink
Cyanosis : no cyanosis 
Clubbing : no clubbing 

Lymphadinopathy : no lymphadenopathy 
Edema : no edema 

VITALS : 
Temperature : 98.6°c/f
PR : 18CPM
RR : 18_cycles per minute
Blood pressure : 130/80 mm of Hg
SPO2 : 99% 


PROVISIONAL DIAGNOSIS : 
          -----------------NEUROPATHY-----------------


Q/A
1. Is this condition temporary or long lasting ?
2 Are there any other possible causes ?
3. Will I be able to recover after taking treatment ?

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