1st internal assessment,general medicine.

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SUMMATIVE ASSESSMENT 2:

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     GENERAL MEDICINE CASE SHEET(june14) CHIEF COMPLAINTS: A 35 year old female, fertilizer factory worker by occupation came to the opd with chief complaints of altered sensorium,lack of energy,fever and loss appetite for 3days,vomiting frequently. HISTORY OF PRESENT ILLNESS:                   Known case of hypertension()..  and recently diagnosed with severe diabetes   and hypersalivation fever-low grade. She quit her job 15 days before the development of symptoms and attended to a function 3days before the development of symptoms. HISTORY OF PAST ILLNESS: k/c/o :HTN Not k/c/o: diabetes  surgical history: umbilical hernia  PERSONAL HISTORY: Diet:mixed Appetite:decreased Bowel and bladder mixed: normal Addictions: none FAMILY HISTORY: normal  GENERAL EXAMINATION : Pallor:not seen Cyanosis:not seen Icterus:not seen  Lymphadenopathy:not seen Clubbing:not seen Oedema:not seen VITALS : Temperature: febrile  Pulse rate: 100/min  Respiratory rate : 22/min  BP: 140/90 SpO2 : 94% SYSTEMIC EXA
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