GM case-2
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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