gm case 3

CASE SCENARIO 


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

Patient details:
50 yr old female who is a housewife resident of miryalguda 

Chief complaints :
Patient is apparently a symptomatic since 2 years back first she developed swelling of left lower limb then swelling progressed to whole body and got treated and swelling subsided. Generalized weakness, fatigueability loss of appetite weight loss. SOB grade (2-3) not cough cold no PND no orthopaedic. Fever intermittent low grade chills subsided with medication. Found to have anemia trasfused 5 units of blood in span of 20 days 

HOPI:
Past illness- 
diabetes-no
Hypertension-no
Asthama-no
Tuberculosis-no
Blood transfusion- 5 units

Personal history:
Mixed diet 
Loss of appetite
Urine -hematuria, blood in urine
Bowl-normal
Addictions-no
Allergies-no

Family history - not significant

General examination:
Pallar- present
Icterus-present
Cynosure -no
Edema-no
Malnutrition-yes
Clubbing-no
Pedal edema-no

Systemic examination
Respiratory:

Inspection
Chest - symmetry
Movement-equal
Trachea-midline
No scars, no sinuses
Apical impulse-5 th inter coastal
Drooping of shoulder-normal
Supra clavicular hollowing- present

Palpation
All inspector findings are confirmed
Midline- trails sign
Apical impulse -5th inter coastal

Percussion
Supra clavicular
Infra clavicular
Mammary
 axillary
Infra axillary
Supra scapular
Inter scapular
Infra scapular 
Are normal

Auscultation
Normal breathing sounds 
No wheeze



Abdominal:
Inspection 
shape-normal
No distention
Umbilicus inverted
Skin stretched
 
Palpation
All inspector findings are confirmed
No local rise in temperature
Tenderness left epi gastric

Percussion 
Dull on left epi gastric

Auscultation 
Dull sounds 





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