GM CASE

July 31, 2023

Case scenario 
Im Sanjana MP ,3rd year bds student. This is an online elog book to discuss our patients health data after taking her consent.  This also reflects my patients centered online learning portfolio.

Case history
A 65 years old woman , who is a home maker

Cheif complaints: 
Patient was brought to hospital with pain in right lower limb , fever since 1week and shortness of breath since 1week

History of present illness:
Patient was apparently asymptomatic 1week back. Then she had pain in right lower limb insidious in onset and gradually progressive type.
Fever- low grade,intermittent associated with chills and relieved by medication 
Shortness of breath - grade 2
Decreased urine output since 1year
Constipation- passes stools in every 2-3 days

History of past illness:
Hypertension- since 10years ,medication( amlodipine)
No h/o DM, TB , CVA,CAD,asthms,epilepsy.
No h/o abdomen pain, burning micturition, chestpain,palpitations 
No h/o surgeries. 

Personal history: 
Appetite- lost
Diet- mixed
Bowel- constipation 
Micturition- decreased urine output 
Known allergies- no
Addictions- no

Family history:
Not significant 

General examination:
Pallor- no
Icterus- no
Cyanosis- no
Lymphadenopathy- no
Clubbing-no 
Oedema-no 

Systematic examination:
Cardiovascular system:
Thrills- no
Cardiac sounds- s1, s2,
Cardiac murmurs- no

Respiratory system : 
Dyspnoe-no
Wheeze- no
Position of trachae- central 
Breath sounds- vesicular 

Gastrointestinal system: 
Shape of abdomen- scaphoid
Tenderness- no
Palpable mass- no
Hernial orifice- normal 
Free fluid- no
Liver- not palpable 
Spleen - not palpable 
Bowel sounds - yes

CNS :
Patient is conscious,  coherent,  cooperative. 

Provisional diagnosis: 
Pyrexia



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