case 6

GM Case -6
5 june 2023
Case scenario.....
Hi, This is Sara Pranathi,IIIrd BDS. This is an online eblog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.
                           CASE HISTORY
Patient details : A 50 years old women, occupation house wife, Resident of pochampalli
Chief complaints:
Patient came to hospital with hand and legs swelling and vomiting
History of presentillness :
Patient was asymptomatic last 10 days back. Swelling in hands and legs since 10 days, vomiting since 2days 
Vomiting characteristics : 2episodes/day ,non bilious, non blood content, non projectile
History of pastillness: 
Hypertension since 4 years 
Diabetes mellitus since 10 years
No tuberculosis, epilepsy, CAD, CVA
left hand fracture 4year back and right hand fracture 3 year back
Family history: 
No significant family history
Personal history:
Diet : mixed
Sleep : normal
loss of appatite
Bowl movement: irregular
Addiction: alcoholic stopef 22year ago
General examination:
Patient is concious and co-operative 
Pallor, icturous present 
No cyanosis, lymphadenopathy, clubbing, oral diseses
Built: normal
Mixturation : irregular 
Systemic examination : (RESPIRATION SYSTEM) 
Inspection:
Upper respiration: 
Nasal septum middle
No Nasal polyp , halitisis present, oral hygiene present
Lower respiration:
Chest symmetrical, eliptical, trachea middle, 
no drooping of shoulder, supraclavicular /infraclavicular hallowing , harrisons groove, kyphoscoliosis, winging of scapula , scars, sinus
Palpitation :
Trachea in middle, 
No tracheal tug, crowding of ribs 
Apical impulse is present
Chest movement normal
Measurement of chest :
Whole : 60 cm
Transverse :30 cm
Antiroposterio:18 cm
Hemi thorax  expansion: 4 cm
Percussion:
Uncooperative
Auscultation:
Breath sound normal


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