Gm case 4

CASE SCENARIO 

HI,Im C.Srivally 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. 

chief complaint 

A 65 year old female daily labourer by occupation,resident of suryapet came to the opd with chief complaints of Fever and SOB since 3 days.

History of present illness 

Pateint was apparently asymptomatic 3 days back then she developed fever high grade intermittent, associated with chills and rigors associated with body pains and weakness.

Patient was taken to near by hospital and was found to have high sugars and treated conservatively.

Patient also complaint about SOB since 3 days which is grade 2-3, increased on lying down and relieved by sitting.

No complaint of chest pain, palpitations

Normal urine output

No complaint of pedal edema, facial puffiness

Complaints of tingling sensation of hands and feet

Complaints of ulcer over Right foot after thorn pick injury

Five years ago patient developed giddiness for which she went to local hospital in suryapet and was diagnosis as Diabetic type 2.Since then she was on medication . 1 year ago she went for hospital for sudden left side paralysis which was diagnosed as CVA.

At the same time she was diagnosed with Hypertension and was on medication since then.  

History of past illness 

Patient is a known case of type 2 diabetes  since 4 yrs.

On medication insulin from 1 year

Known case of hypertension 1 year and on medication

Known case of CVA Since 1 year with hemiperesis

And on medication 

Not a known case of CAD, Thyroid disorders, Asthma and epilepsy.

Personal history 

DIET: MIXED.

APPETITE: DECREASED

SLEEP: ADEQUATE.

BOWEL AND BLADDER: REGULAR                  

ADDICTIONS: NO ADDICTIONS 

FAMILY HISTORY:

Not significant 

SURGICAL HISTORY:

ABDOMINAL HISTERECTOMY 25 YEARS AGO

General examination::

Patient is conscious,coherent , cooperative 

He is well built and moderately nourish

Pallor present

Icterus: Absent 

Cyanosis: Absent 

Clubbing: Absent 

Lymphadenopathy: absent 

Edema:absent


SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM:

Inspection:-

Upper respiratory tract - oral cavity, nose & oropharynx appear normal. 

Chest appears Bilaterally symmetrical & elliptical in shape

Respiratory movements appear equal on both sides and it's Abdominothoracic type. 

Trachea central in position & Nipples are in 5th Intercoastal space

No dilated veins,sinuses, visible pulsations.

Palpation:-

All inspiratory findings confirmed

Trachea central in position

Apical impulse in left 5th ICS, 1cm medial to mid clavicular line

Percussion:

Supraclavicular -Resonant

Infraclavicular-Resonant

Mammary-Resonant

Infra axillary-Dull

Suprascapular-Resonant

Interscapular-Resonant 

Infrascapular-Resonant 

Auscultation:

Infraclavicular- (NVBS) (NVBS)

Mammary- (NVBS) (CREPTS)

Axillary- (NVBS) (NVBS)

Infra axillary-(NVBS) (CREPTS)                 

Suprascapular- (NVBS) (NVBS)

Interscapular- (NVBS) (NVBS)

Infrascapular- (NVBS)(NVBS)

 GIT EXAMINATION 

Shape of abdomen-scaphoid

Tenderness-No

Palpable mass-No

Liver- Not palpable

Spleen - Not palpable

Bowel sounds- Normal


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