case 7

GM Case -7
24 july 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

Cheif complaint:
A 60yr old female came with complaints of fever since 10 days -productive cough and pain in left chest region while coughing since 10 days -vomitings since 10days 

HOPI -
Patient was aparently asymptomatic 10 days back and She then developed fever low grade,intermittent,not associated with chills and rigors,relieved on medications C/o cough with expectoration since 10 dayswhitish mucoid sputum not blood tinged
C/o nausea and vomitings since 10days 2-3episodes per day which is watery,non projectile ,non blood tinged with food particles as contents
C/o constipation and decreased appetite since10 days
C/o pain in the back while coughing
No H/O Burning micturition, loose stools, pain abdomen
No h/o pedal edema,chest pain, facial puffiness ,decreased urine output,SOB,palpitations

Past History-
No similar complaints in the past
N/K/C/O - DM,HTN,TB, Asthma, Epilepsy, CVA,CAD , Thyroid disorders.
H/o NSAID abuse present

Personal History-
Diet- Mixed
Appetite- Decreased since 10 days
Bowel & Bladder Movements-H/O Constipation
since 10 days
Sleep - Adequate
Addictions - None

Drugs :
1.Inj- NEOMOL 1gm SOS
2.Inj.OPTINEURON 1AMP IN 100 ML NS IV/OD 3.Inj.Zofer 4mg IV/BD
4.Tab.PCM 650mg PO/BD
5. Tab.levocetrizine PO/BD
6.IV FLUIDS NS,RL @75ml/hr
7. SYP.ASCORYL -LS 5ML PO/TID 
8.SYP.CREMAFFIN PLUS 15ML PO/BD

Family history- Not Significant

GENERAL EXAMINATION-
Patient is Conscious, Coherent and Co Pallor present
operative.
Pallor present 
Icturus present
No Edema , lymphadenopathy, clubbing, cynosis
Vitals
BP. 100770mmHg
PR: 112 bpm
RR-16cpm
Spo2-98% @RA

Systemic Examination:
CVS: 
Inspection 
Chest wall is bilaterally symmetrical. No precordial bulge is seen

Palpation
JVP- Normal
Apex beat -felt in the left 5th intercoastal space in the mid clavicular line

Auscaltation-
S1&S2 are heard,no murmur found.

RESPIRATORY SYSTEM
INSPECTION :
Middle Nasal septa, no nasal polyp,no halitosis
Lower respiratory
Chest symmetrical, 
Position of trachea- central, no drooping of shoulder, no supraclabicular/infraclavicular hollowing
Palpitation:
Trachea midline,
No tracheal tug, crowding of ribs, 
Apical impulse present, chest movements normal
Auscultation: 
Bilateral air entry, normal vesicular breath No added sounds
sounds are heard.
Grade-3 SOB

Chest x-ray PA view
CNS:
Patient is conscious,coherent and co operative
well oriented to time and space.
Speech normal.
No signs of meningeal irritation.
Motor and sensory system- Normal Reflexes - present
Cranial nerves - intact

PER ABDOMEN
 inspection:
All quadrants are moving equally with respiration No scars, engorged veins,sinuses.
Umbilicus - central and inverted

 Palpation::
Superficial palpation- No Local rise in temperature and no tenderness Deep palpation- No guarding, rigidity

 Percussion::

Tympanic note - heard

Auscaltation:
Bowel sounds heard

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