GM CASE 7

GM CASE 7
Case scenario......
             Hi This is P.Bhavana,3rd BDS student.This is an online eblog book discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.

Case sheet : A 60 yr old female came with complaints of fever since 10 days.
Productive cough since 10 days.
Vomitings since 10 days.

HOPI: Patient  was apparently asymptomatic 10 days back.she then developed fever low grade,intermittent,not associated with chills and rigors,relieved on medications.
C/O cough with expectoration since 10 days
Whitish mucoid sputum not blood tinged with food particles as contents.
C/O pain in the back while coughing
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
Appetitte- Decreased since 10 days 
Bowel &Bladder Movements - H/O Constipation since 10 days 
Sleep- Adequate 
Addictions- None
Family history- Not significant

GENERAL EXAMINATION-
Patient is conscious,coherent and Co operative.
Pallor present
No signs of icterus , clubbing,cyanosis,Lymphadenopathy

Vitals -
TEMP:100.6F
BP:100/70mmHg
PR:112bpm
RR -16cpm
Spo2-98%

Systemic Examination
CVS: 
INSPECTION
chest wall is bilaterally symmetrical .
No precordial buldge is seen

Palpation 

JVP- NORMAL 
APEX BEAT - ,felt  in the left 5th intercoastal
Space  in the mid clavicular line 
AUSCULTATION 
S1&S2 are heard , no murmur found.

RESPIRATORY SYSTEM:

Position of trachea -  central 
Bilateral air entry ,normal vesicular breath 
Sounds are heard .
No added sounds

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


On inspection:
All quadrants are moving equally with respiration 
Umbilicus - Central and inverted 
No Scars ,engorged veins,sinuses.

On percussion:
Tympanic note  heard 


ON AUSCULTATION
Bowel sounds heard 

PROVISIONAL DIAGNOSIS:
 PYREXIA UNDER EVALUATION

Chest x- ray PA view

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