GM case 9

Hii this is  k.priyanka,3rdBDS student.This is an online eblog book to discuss our patients health data after taking his consent . This is reflects my patient centered online learning portfolios

Case scenario:
An 23 yr old female occupation is store manager came to the hospital for he has an severe upper abdomen pain

Chief complaint:
C/O pain in the left side of abdomen in the upper quardant on and off since 1year.

History of present Illness:
Patient was apparently asymptomatic a year ago
H/o loss of appetite (+), fatigue (+),(easy fatigulibilty)
No H/o fever/cough/constipation/Nausea
No H/o pedal edema /bleeding manifestation.
History of past illness:
At the age 13 started developing pain in the (L)hypocondrium dragging type radiating to left strenal region each episode lasting for one hour and aggregated on supine position and relieved when lying on proue position 
Used medication for pain suggested by local rmp
Frequency of pain :once in a month
C/o sob on excretion and easy fatigulibilty at 11 years 
At 16 yrs of age started developing gaidium (monthly once) associated with frequent onset of fever and in which hospital found to be having low Hb and started on oral medication for one month 
Decreased appetite from 13 yrs of age 
Bil forntal region headache on & off since 13 years 
Decreased vision since 13 yrs 
HTN(-)Tb(-)DM(-) epilepsy (-)CAD(-)
Personal History:
Diet: mixed
Appetite:loss 
Bowel: regular
No known allergies
No Addictions 

Family History:no relavent history
Physical examination
General Examination:
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No oedema
Malnutrition:yes
No dehydration
Temperature:98.6C/F
Pulse rate:86/min
Respiratory Rate:16/min
Bp:110/70mm/Hg.




Systemic Examination:

Systemic Examination:


Respiratory system:
Dysponea:Yes on excretion
No wheeze
Position of trachea: Central
Breath sounds: vesicular

Abdomen:Shape: scaphoid
Tenderness:yes hypocondrium
Palpable mass:yes
Free fluid :No
Liver :not plapable
Spleen : plapable
Bowel sounds :yes

Central Nervous system:
Conscious
Speech: Normal

Provisional diagnosis: pancytopenia

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