Gm case 2

March 1st 2023
Case scenario.....
Hi, this is C.Srivally, IIIrd BDS. This is an online eblog book discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.

 CASESHEET:a 85 year old women has come to hospital in an unresponsive state. 


Chief complaints: fever  and chills since past 10days,burning Micturition and pain in the abdomen, vomitings, and also not taking fuilds or liquids since 2 days. 

HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic before 1month.
Since 1 month  the patient is suffering from mild joint pain. And then the patient was suffering from fever and abdominal pain since 10 days, and  loss of appetite  I.e. not taking any fluids or liquids from last 2 days.
Suddenly the patient was unconscious and was not talking to anyone.



Associated diseases:
Hypotension 
Gastric acidity.

 
History of past illness:
The patient has taken an gall bladder removal surgery(cholecystectomy) before 10 years.





PERSONAL HISTORY: 
Appetite : decreased 
Diet: vegetarian 
Bowel and bladder movements: irregular 
Addictions : Nil
Micturition: normal
Known Allergies : nil

FAMILY HISTORY: 
Not significant 

GENERAL EXAMINATION:
Pallor : no
Icterus :no
Cyanosis : no
Clubbing : no
Lymphadenopathy : no
Edema : no

VITALS:
Temperature: 98.6°c/f
Pulse: 88 beats per minute
Respiratory rate: 15 cycles per minute
Blood pressure: 111/50 mm of Hg
SPO2: 100%

SYSTEMIC EXAMINATION:

The patient has became very thin and is 
Not responding .
Oral cavity- normal oral hygiene.

  Cardiovascular Examination:
Thrills: no
Cardiac sounds: S1, S2 heard
Cardiac murmurs: No


PROVISIONAL DIAGNOSIS:
Uremic encephalopathy 
Moderate Lv dysfunction. 

Questions from patient :
Will she become normal again? 
                                 ( from their relatives)

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