GM case:02
Hi, I am Pranavi Thavidaboina of 3rd year dental student . This is an online E logbook to discuss our patient’s health data shared after taking his/her/guardian’s consent. This also reflects our patient centered online learning portfolio.
The patient’s consent was taken verbally prior to history taking and examination of his/her condition.
A 17 year old patient studying Bsc came to general medicine OPD with the chief complaints of dragging pain in the neck
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 3 days ago
He developed dragging pain in the neck since 3 days, when he was in hostel
He had given blood sample few days prior in Miryalaguda which revealed low hemoglobin
He was then admitted in KIMS where he developed back pain
HISTORY OF PAST ILLNESS:
He had similar complaints at the age of 8 for which he had undergone blood transfusion along with medication
No known Diabetes Mellitus , Hypertension ,TB , epilepsy , thyroid disorders, asthma.
FAMILY HISTORY:
Father is hypertensive
No family member had similar complaints
PERSONAL HISTORY:
Normal appetite
Mixed diet
Regular bowel habits
Normal micturition
No addictions
No allergies
GENERAL EXAMINATION:
Patient was conscious, coherent and cooperative
Moderately built
Moderately nourished
Patient was icteric
No pallor, lymphadenopathy, clubbing, cyanosis, pedal edema
Vitals:
Temperature: 99.7 °F
Pulse rate : 98 beats/min
Respiratory rate:19 breaths/min
Blood pressure: 120/80 mm Hg
SpO2: 98%
GRBS: 152 mg/dl
LABORATORY INVESTIGATIONS:
FEVER CHART:
ECG:
Questions :
How long will it take to cure this pain ?
