General medicine 9

GM case
Case scenario..
 Hi,I am K.Sahalypa,3rd BDS 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.

Chief complaints 
Patient complains of fever since 4 Days
History of present illness 
Patient was apparently asymptomatic 4 days ago,then he developed fever of high grade associated with chills and rigors not associated with cough,cold,sore throat,Shortness of Breath,palpitations and Abdominal pain.
He had Vomitings 3 episodes 3 days back,Non billious,Non projectile,contain food particles as content.
No History of Hematuria,Hematemisis.
No History of blood in stools,no other bleeding manifestations.
History of past illness
Hypertension-No
Diabetes mellitus-No
CVA-No
CAD-No
Asthma-No
Tuberculosis-No
Epilepsy-No.
Personal History 
Diet-Mixed 
Appetite-Normal 
Bowel&Bladder-Regular 
Allergies-No known allergies 
Addictions-No addictions
Family History 
No similar complaints seen in the Family 
General examination 
Patient is conscious,coherent,Cooperative,well oriented to time,place and person.
Moderately built and nourished.
Pallor-Absent 
Icterus-Absent 
Cyanosis-Absent 
Clubbing-Absent 
Lymphadenopathy-Absent 
Oedema-Absent.
Vitals
Pulse rate -65/min
Respiratory rate-16/min
Blood pressure-130/80 mm/hg
SPO2-98%
Systemic examination 

Cardiovascular System 
Thrills -No
Cardiac sounds-S1S2
Cardiac murmur-No

Respiratory System 
Dyspnoea-No
Wheeze-No
Postion of Trachea-Central 
Breath sounds-Vesicular

Abdomen 
Shape of the abdomen-Obese
Tenderness-No
Palpable mass-No
Hernial orifices-Normal
Free fluid-No
Bruits-No
Liver-Not palpable
Spleen-Not palpable
Bowel Sounds-No 

Provisional Diagnosis 
Viral pyrexia with thrombocytopenia 
Dengue

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