General medicine Case 3
March 06,2023
Case 3
February 06,2023
Case scenario..
Hi,I am V.Sreeja,3rd 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 18 years old female came with a
Chief complaint of increase in body temperature since 2 weeks
And also vomitings since 6 days
Irregular menstrual cycles once in 60 to 90 days
History of present illness
The patient is asymptomatic 2 weeks ago then she is associated with continuous low grade intermittent fever associated with chills.She is also associated with 1 to 2 episodes of vomitings per day for 3 days which are non projectile, bilious,watery,greenish colour and the amount of food she had consumed get vomited and she is also associated with abdominal pain which is at umbilical region which is not radiating and the blood test report shows decreased count of platelets.
History of past illness
Hypothyroidism since 10 years
No tuberculosis
No diabetic mellitus
No asthma
No hypertension
No epilepsy
Family history
Mother with Hypothyroidism since 10 years
Personal history
She is unmarried
Diet-vegetarian
Sleep-adequate
Appetite-loss of appetite
Urine and Bowel movement-normal and regular
Addictions:alcohol-no
Tobacco-no
Menstrual cycle:The patient had developed irregular menstrual cycles once in 60 to 90 days associated with heavy menstrual bleeding soaking 3 to 4 pads per day.
General examination
Pallor-mild
Cyanosis-no
Jaundice-no
Clubbing of fingers or toes-no
Oedema of feet-no
Lymphadenopathy-no
Pulse rate:78bpm
Bp:100/70mmHg
Provisional diagnosis:pyrexia decreased thrombocytopenia
Questions:
Are their any specific kind of foods that the patient needed to avoid during medication as she is hypothyroid patient?
Does the heavy menstrual bleeding of the patient can be reduced?