case 8

GM Case -8
31 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:
A74 years old male from dislicgerla came with complainta of both legs swelling , chest pain, breathing since 2 months
History of present illness:
Patient was apparently asymptomatic since 3years back
Both legs swelling extend upto mid calf from 2-3 years it is intermittent , pitting type edema 
Chest pain since 3 months continues with radiation 
Breathing since 2 months no aggressive or releaving factors , breathing progress to grade 2 to grade 3
History of past illness: 
Diabetes since 15 years
Hypertension since 10 years 
Edema since 3 years
No similar complaint like epilepsy, asthma, CVA, T. B
Drugs:
Amicloxand didoxacillin capsules
Levocetirizine
Supracyn
Metformin hydrochloride ip 500mg
Telmisartan tablet 400mg 
Personal history:
Diet: mixed
Appatite: normal
Mixturation:increased output
Bowl and bladder movements normal
Sleep inadequate
Addiction : 30 years back (chutta for 2-3 month and stoped) 
No Alcohol

Family history:
No similar complaints are seen

General examination:
Patient is consious and cooperative
No pallor, icturus, clubbing, cynosis
Pedal edema is prest 
Built: obese
Vitals: 
Temperature:98.2 F
Pulse rate 80 bpm / min
Respiration rate 16 cpm
Spo2 :98



Systemic Examination:
CVS
Inspection::
Symmetrical chest wall, 
Elliptical chest
Apical impulse present
No dilated vein, ateries, precordial bulge, kypokoliosis, pectus carnivatum/ excavatum
Scare is present on chest 

Palpation:
Apical impulse normal
Less vibrations on left side

Percussion:
No gerhards sign
Left heart boarder dullness 
Right heart boarder normal

Auscultation:
Less sounds in left side compared to right side

RESPIRATION:
Inspection:
Chest symmetrical
Elliptical chest
Trachea in midline
Apical impule present
No drooping of shoulders, supra clavicular and infra clavicular hallowing, winging of scapula, kypokoliosis
Widening of ribs normal
Palpation:
Trachea midline
Chest movements normal
No intercostal widening of ribs, tenderness
On expiratin there is gap 1cm
Tactile frenitus low vibration on left side of scapula
Auscultation:
Normal breath sounds
Grade 3 SOB




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