GM-CASE 6

Gm-Case 6
Case scenario

Hi, this is P. Vennela, IIIrd BDS. This is an online eblog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio. 

                          CASE HISTORY

Patient details:
A 60 yr old female resident of nalgonda came to hospital with
Chief complaint:
fever since 10 days
-productive  cough since 10 days
-vomitings since 10days
History of present illness:
Patient was aparently asymptomatic 10 days back.She then developed fever low grade,
intermittent ,not associated with chills and rigors ,relieved on medications. 
And nausea and vomitings since 10days 2- 3 episodes per day which is watery ,non projectile ,non blood tinged with food particles as contents. 
constipation and decreased appetite since 10 days. 
 cough  with whitish mucoid sputum not blood tinged since 10 days. pain in the back while coughing . 
History of past illness:
No similar complaints in the past. 
No diabetes, asthma, TB, epilepsy, chest pain. 
Personal history:
Diet- Mixed
Appetite- Decreased since 10 days
Bowel & Bladder Movements- normal
H/O Constipation since 10 days
Sleep - Adequate
Addictions - None. 
Family History:
No significant family history. 
General examination:
Patient is Conscious, Coherent and Co operative .
Pallor present
No icterus
No clubbing
No cyanosis
No lymphadenopathy
No pedal oedema

SYSTEMIC EXAMINATION:
RESPIRATORY SYSTEM:
Position of trachea- central
Bilateral air entry, normal vesicular breath sounds are heard.
No added sounds

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.

ABDOMEN:
On inspection:
All quadrants are moving equally with respiration
Umbilicus - central and inverted
No scars, engorged veins ,sinuses.
On palpation:
Superficial palpation- No Local rise in temperature and no tenderness
Deep palpation- No guarding, rigidity
On percussion:
Tympanic note - heard 
On auscaltation:
Bowel sounds heard . 

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