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
