GM - 03

February 27 2023

Case 3

February 27 2023

Hi, I am V.Shivani 3 rd sem dental student . This is online elog book to discuss our patient health data after taking her consent . This also reflects my patient centered online learning portfolio .

CASE SHEET : A 70 year old female came with a complaint of fever and cold .

CHIEF COMPLAINT :

Intermittent fever since 15 days

Cold from 3 days associated with dry cough

Cough is present since 2 days and it is occasionally seen.

HISTORY OF PRESENT ILLNESS :

The patient was apparently asymptomatic 15 days before,then developed fever 15 days back also had cold from 3 days associated with dry cough that is no sputum .

Fever is intermittent it is reduced when medication is used .

Patient also had body pains , non radiating chest pain.

She also had knee pains .

Blood test reports had shown decreased levels of haemoglobin.

Patient has dry mouth and feels thirsty frequently.

PAST ILLNESS:

Hypertension - present since 30 years

Diabetes mellitus - present from 20 years

PERSONAL HISTORY :

Diet - Vegetarian diet

Appetite - normal

Sleep - normal

Bowel and bladder - normal

Addictions - No addictions 

DRUG HISTORY:

GENERAL EXAMINATION:

Built - normal

Nourishment - well nourished 

Consciousness - in conscious

Pallor - pale pink

Cyanosis - no

Clubbing - no

Edema of feet - present 

Lymphadenopathy - no

BIOCHEMICAL INVESTIGATION:

PROVISIONAL DIAGNOSIS:

Suspected case of Anaemia

Q/A

1. The patient is having hypertension and diabetes , does the new medication given to treat anemia affect those conditions.If so how to prevent it ?

2. Are there any other possible diagnosis with the given information?