gm case-4 roll no .25

July 21 2023

CASE scenario....

Hi, I am G.Harini 3rd BDS student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolio.

                 CASE HISTORY

Patient details:

A 60 year old female known case of suffering from fever chills

Chief complaint:

Associated with Fever with chills  since 20 days

Productive cough since 10 days

Vomitings since 10 days

History of present illness*

*Patient was apparently asymptomatic since  1 month back then she is suffering with fever. With chills  since 20 days which is low grade; intermittent and rigors which is relived by medication 

* cough since 10 days which is whitish ; mucoid sputum

*Nausea and vomiting since 10 days ,2-3 times per day which is water,non-projectile,not blood; food particles content

*Constipation and apetite since 10 days  

And pain radiates from back while coughing  and decreased urine output while fever 

*She has bitter taste

Past history:

No hypertension,asthma ,tuberculosis

Patient is not a known case of thyroid 

Non diabetic

Joint pains since 2 months back relieved on Medication

Family history:

No family history

Personal history:

Patient is conscious and cooperative

Diet: mixed diet

Apetite: loss of appetite 

Sleep:normal 

Micturition: burning micturition  nd decreased urine output 

Bowel: constipation 

Known allergies:no

Addictions : nill 

*General examination:

Pallor:yes 

Icterus:no

Lymphednopathy:yes which is on left side of neck

Clubbing:no

Malnutrition:no

Edema of feet: no

vitals: 

Pulse rate -112/min

Tem-98.9c/f

Respiratory rate-16/min

Bp-100/70mm/hg

Respiratory system:

Systemic examination: 

1) inspection: 

Oral hygiene and caries on molars 

Chest shape is bilateraly symmetrical

Position of trachea is central

Scars are present on supraclavicular region

Dilated veins on fingers

2) palpation

Trachea:midline 

Movement of chest is equally expanded in anterior and posterior and in apical

3) percussion

Right or left clavicular percussion sound normal

4) auscultation

Breath sounds are normal 

Wheeze :no

Breath sounds vesicular

Abdomen:

Shape is schapoid

Umbilicus - central ,inherited

No tenderness

Liver and spleen not palpable

Free fluid -no

Bowel sounds- yes

Cvs:

Thrillss :no