case 9

Hi, I am sai kaushik, 3rd year 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.

CASE SHEET:60year old women with fever.

Chief complaints: complaint of fever since 5days and nausea and diarrhoea 
Generalized weakness since 5days
Nausea and decreased appetite since 5 days
A 60 year female came to OPD complaint of high grade intermittent fever with chills relived on medication.History of generalized weakness since 5 days and nausea decreased appetite since 5 days and diarrhoea.
History of abdominal discomfort as loose watery diarrhoea.
No history of headache /cold/cough/chestpain

History of present illness:
admitted for treatment 

ASSOCIATED DISEASES:nil

PAST HISTORY:Normal fever


PERSONAL HISTORY:
Nil


FAMILY HISTORY:nil

GENERAL EXAMINATION:
No pallor
Cynosis :no
Lymphadenopathy: no
Malnutrition:no
Dehydration:mild
Icterus:no
Clubbing of finger:no
Oedema of feet:no


VITALS:
Temperature: 100.1°f

Pulse:_82__beats per minute

Respiratory rate: _24__cycles per minute

Blood pressure: 130/80____ mm of Hg

SPO2: ___


SYSTEMIC EXAMINATION:

Cardiovascular system:

no thrills
nomurumurs
Cardiac sounds: S1, S2 ____

Respiratory system:

__no__ dyspnea
___no_ wheezing
Breath sounds heard: vesicular

Abdomen: scaphoid
No tenderness
No palpable mass
Non palpable liver
No bruits
No Bowel sounds

Central Nervous System:

Conscious:normal
Speech: __normal____


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

27 February,2023
February 27,2023
Case scenario.......

Hi, I am P.Minnu ,3rd yr 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.

CASE SHEET:

Chief complaints: chest pain central and radiating to shoulder and shortnes of breathe 
History of present illness:patient was apparently normal 11 days ago, then he suddenly developed chest pain radiating to abdomen
Type of pain:dragging type 





HISTORY OF PRESENT ILLNESS:
Difficulty in breathing
Chest pain radiating to abdomen



ASSOCIATED DISEASES:Nill





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



PERSONAL HISTORY:
Appetite normal , mixed diet ,bowels regular, mituration 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

Abdomenshape: 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:
Biochemical investigations:




Questions:
How long will it take to cure the problem and is it curable?

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