FEBRUARY 25,2023
GM case 2
Case scenario.....
Hi,this is P.Bhavana, 3rd BDS student.This is an online eblog book to discuss our patient's health data after taking his consent.This also reflects my patient centred online learning portfolio.
CASE SHEET:
A 4 year child with haematuria.
Chief complaint:
Painless red coloured urine since 6 months
Cough and cold since 2 days
No fever
No vomitings
No pain in abdomen
No trauma.
HIistory of present illness:
No history of facial puffiness
No pedel edema
History of past illness:
Recurrent episodes of cystitis,hematuria,proteneuria
Personal history:
Occupation:student
Appetite: normal
Diet: mixed
Sleep: regular
Bowel and Bladder: regular
Family history : not significant
General examination:
Height:100cm
Weight:15kgs
Pallor : no
icterus:no
Cyanosis:no
Lymphadenopathy:no
Malnutrition:no
Dehydration:no
VITALS:
Temperature:98.2°F
Pulse rate:112 beats per minute
Respiratory rate:24 cyclesper minute
Bp:110/90mmHg
Spo2:99%
Systemic examination
Cardiovascular system
Thrills : no
Cardiac sounds: S1,S2
Cardiac murmurs : no
Respiratory system
Dyspnoea: no
Wheeze:no
Position of trachea: central
Breath sounds : vesicular
Abdomen :
Shape of abdomen : scaphoid
Tenderness:not
Liver : not palpable
Spleen: not palpable
Provisional diagnosis:Renal calculi
Investigations :
Questions from patient:
1.How long will it take to cure?
2.Does it lead to serious complications?
Questions from my side:
1.How haematuria is related to renal calculi?
2.why there is no pain in abdomen,if it is renal calculi?