GM case-2

 


 A 68years man presented with shortness of breath and chest pain


06 March,2023

March 06,2023

Case scenario.......


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


CASE SHEET:


Chief complaints: chest pain central and radiating to abdomen and shortness of breathe,pedel edema

History of present illness:patient was apparently normal 11 days ago, then he suddenly developed chest pain radiating to abdomen.

Shortness of breathe is sudden and exertion i.e grade 2.Shortness of breathe is relived by taking rest


Pedel edema is present which is pitting type

Type of pain:dragging type 



PAST HISTORY:he is asymptomatic since a week,but suddenly he faced a chest pain from a week




PERSONAL HISTORY:

He is a farmer and married.He goes to field work in the morning return late in evening.But since 10 days..he is unable to walk..as he is experiencing breathless while walking..So he visited hospital

Appetite normal , mixed diet ,bowels regular, micturition normal , no known allergens.


Addictions:alcohol since 30yrs




FAMILY HISTORY:

No prominent history


DRUG HISTORY:DYTOR PLUS 10TAB

                              PREDMET 16mg

                              REPAN-DSR

                              MUCAINE gel

                              CO2 TAB




GENERAL EXAMINATION:

>Pallor : Not present


>Icterus : Not seen


>Cyanosis : Not seen


>Clubbing : Not seen


>Lymphadenopathy : Not seen



>Edema : Not seen


VITALS:

Temperature: 98.6c/f


Pulse:_88__ beats per minute


Respiratory rate: 14__cycles per minute


Blood pressure: ____110/70 mm of Hg


SPO2: ___98


SYSTEMIC EXAMINATION:


Cardiovascular system:


_no__ thrills

No___murumurs

Cardiac sounds: S1, S2


Respiratory system:


__no__ dyspnea

__no__ wheezing

Breath sounds heard: vesicular


Abdomen Shape: scaphoid 



No tenderness

No palpable mass

Non palpable liver

Non palpable spleen

No bruits

Bowel sounds: heard


Central Nervous System:


Conscious: normal 

Speech: normal______


INVESTIGATIONS:








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