General medicine case-02

 Hello, I am P.Aishwarya ,3rd semester student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolios

CASE SCENARIO:
CASE SHEET:
 A 54 year old female , resident of nalgonda came to causality with chief complaints of decreased apetite , vomitings , fever and Shortness of breath.

 HISTORY OF PRESENT ILLNESS:
She has Decreased apetite and vomitings since 6 to 7 days and fever since 7 days which is intermittent and relieved on medications and shortness of breath since 8 days.

PAST HISTORY:
Patient is suffering with Type 2 Diabetes Mellitus  since 30 past years(she was on medication)
Hypertension since 20 years (on medication)

TREATMENT HISTORY:
For Diabetes Mellitus since 20 Years and 
FOR Hypertension  since 20 yrs

PERSONAL HISTORY:

-Decreased apitite
-Regular bowels
-Normal micturition
-Chews betal leaf

FAMILY HISTORY:

-No hypertension
-No diabetes
-No heart disease
-No cancers 
-No asthma

GENERAL EXAMINATION:
Pulse rate : 87 per minute 
Respiratory rate : 20/min
B.p : 130 / 80 
Spo :98%
Pallor -present

No Icterus 
No Cyanosis 
No lymphadenopathy

MENSTRUAL HISTORY:
Menopause 

SYSTEMIC HISTORY:

CVS
NO thrills
S1 ,S2 present
No cardiac murmurs
RESPIRATORY SYSTEM:
NO dyspenoea
No wheezing
Central position of trachea

ABDOMEN:
 Abdomen-scaphoid
No palpable mass
No hernial orifices
No bruits
No free fluids
Bowel sounds heard
No palpable liver and spleen

CNS:
Patient is Alert
speech: normal 
No neck stiffness
BIOCHEMICAL INVESTIGATIONS:
 PROVISIONAL DIAGNOSIS:
 









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