Gm case 10

 Case scenario.....

Hi, this is P.Minnu,3 rd BDS student. This is an online e-blog book to discuss our patient's health data after taking his consent. This also reflects my patient centered online learning portfolio.

CASE SHEET:

A 22-year-old female came with chief complaint of fever since 4 days.

CHIEF COMPLAINT:

Fever since 4 days.

Headache since 4 days.

HISTORY OF PRESENT ILLNESS:

Patient is apparently asymptomatic 4 days ago.

When she noticed fever since 4 days.

Patient has intermittent, sudden onset, low grade fever which is relieved on medication.

The fever is not associated with chills and no increase in temperature at night.

Headache since 4 days.

The pain is radiating from left to right.

The pain is continuous, not relieved on medication.

There is no vomiting and shortness of breath. 


HISTORY OF PAST ILLNESS:

No asthma, diabetes , hypertension, tuberculosis, epilepsy, cad

FAMILY HISTORY:

No similar compliment.

PERSONAL HISTORY:

Diet - mixed

Bowel and bladder- regular

Sleep- adequate

Appetite-regular

Addiction- no

Allergy: no

                   

GENERAL EXAMINATION:

Pallor: no

Icterus: no

Cyanosis: no

Clubbing: no

Lymphadenopathy: n0

Edema : no

Built: well built

Nourishment: well nourished

Pulses: Temperature: 102℃

               Blood pressure: 90/60 mm / hg

                pulse : 84


SYSTEMIC EXAMINATION

                                                  RESPIRATORY EXAMINATION

INSPECTION

UPPPER RESPIRATORY TRACK: normal

NASAT SEPTUM: in midline

ORAL CAVITY: no stains , caries are seen

OROPHARYNX: normal

CHEST APPEARANCE: elliptical in shape

RESPIRATORY MOVEMENTS: equal on both sides. 

SYMMETRY: bilateral symmetry

TRACHEA POISITION: in midline

DILATED VEINS: no

SCARS: no

SINUSES: no

VISIBLE PULSATION: no

DROOPING: no

PALPATION: 

trachea is central in position 

apical impulse is normal.

Dilated vein: no

Infra & supra scalloping: no

Chest movements: equal on both sides during inspiration.

Measurements: transverse : 25.5cm

                            Anterio posterior: 20cm

                               AP: T = 

                            Right lobe: 39cm

                            left lobe: 39cm

                            total chest: 78cm

PERCUSSION:

Resonant sounds are heard.

No additional sounds are heard.

                                                            GIT

INSPECTION

UPPPER RESPIRATORY TRACK: normal

NASAT SEPTUM: in midline

ORAL CAVITY: no stains, no caries are seen.

OROPHARYNX: normal

UMBILICUS POSITION: Central inverted

SHAPE : scalloped, equal on both sides. 

FLANGS AND DISTENSION: no

DILATED VEINS: no

SCARS: no

SINUSES: no

VISIBLE PULSATION: no

All quadrants are moving equally on inspiration

PALPATION:

There is local rise in temperature.

Superficially, no palpable mass, no tenderness is seen.

Deep, no palpable liver or spleen.

PERCUSSION:

No fluid thrills, shift in dullness

no puddle's sign.

liver- 7cm

AUSCULTATION:

Bowel sounds are heard.

PROVISIONAL DIAGNOSIS:

Generalized fever & weakness.

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