case 9

5th August, 2023
 GM case -
 Case scenario .....
Hi, I am S. Pranathi, a student  of 3rd BDS. This is an online elog book to discuss our patient health data after taking his consent.  This also reflects my patient centered online learning portfolio .
           
                             Case history

Cheif complaint:
A 670yr old male came with complaints of fever since 2 days and wound on the right foot

History of present illness:
Patient was apparently asymptomatic 2 years ago then he had a wound on the right foot it is not healed since 2 years even he visited so many hospitals 
The pain in the right foot is flight pain,tingling and numbness present
Fever since 2 days, intermittent type
History of past illness:
Diabetes and Hypertension diagnosed incidentally
No similar complaint like epilepsy, asthma, CVA, T. B, edema, chest pain
Drug history:
Personal history:
Diet :mixed
Apetite :normal
Sleep:inconvenience in sleeping 
Bowel/bladder -regular 
Mixturation : normal
No Allergies 
Habits:Alcohol, tobacco, betal nut are stoped

Family history 
No family history complaints

General examination 
Patient was Conscious and Co-operative.
Pallor: present
Icterus:present
Cyanosis:No
Lymphadenopathy:No
Edema-No
Vitals:
Temperature: 101F
Pulse rate:80/min
Respiratory rate : 16cpm
Bp: 140/70mmHg

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.

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

Question from patient :
 • I am suffering from 2 year when my leg going to cure? 
 

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