GM case -12
September 26, 2023
Hello, I am p.aishwarya, a 5th semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.
CASE SCENARIO:
CASE SHEET:
A 55year old female came to casuality with cheif complaints of body pains since 5days.
CHIEF COMPLAINTS:
Case of
- body pains since 5 days.
Patient was apparently asymptomatic 5days ago then she developed fever, later it subsided.
She complains of generalised body pains,fatigue,general weakness.She had lower abdominal pain which is one dragging type.
No aggreviating and relieving factors are noticed. She also complains of suffering from non productive cough associated with chest pain.She also had retrosternal burning sensation which had no aggreviating and relieving factors elicited.
HISTORY OF PRESENT ILLNESS:
She is suffering from retrosternal burning sensation and no aggreviating and relieving factors are noticed.
Loose stools are observed 2days ago.
Not a known case of burning micturition and decreased or increased urine output,loose , constipation,nausea and vomiting.
No history of weight loss.
PAST HISTORY:
-not a known case of HTN/DM/Asthama/thyroid disorder/epilepsy.
PERSONAL HISTORY:
appetite-normal
Regular Bowel movements.
Has normal micturition with no burning sensation.
Has no known allergies.
She has a habit of regular alochol consumption (90ml/day) and betel leaf.
FAMILY HISTORY:
Has no history of Diabetes Mellitus, No HTN, No Cardiac Strokes, No cancer.
MENSTRUAL HISTORY:
She attained menopause 10years ago.
PHYSICAL EXAMINATION:
A.GENERAL EXAMINATION:
No pallor
No interest
No cyanosis
No clubbing of fingers
No generalized lymphadenopathy
No pedal edema
Vitals:
Pulse rate : 116 per minute
Respiratory rate : 20/min
BP:110/60
Temperature:she is afebrile
SYSTEMIC EXAMINATION:
B. CARDIOVASCULAR SYSTEM:
No thrills
S1, S2 heard
No cardiac murmurs
C.RESPIRATORY SYSTEM
No dyspnea
No wheeze
Position of trachea: Central
Breath sounds:vesicular
D.ABDOMEN:
Shape of abdomen:schapoid
No tenderness
No palpable mass
Herneal orifice-normal
Free fluid-no
Bruits-no
Liver-not palpable
Spleen-not palpable
PV examination:normal
E. CNS:
Level of consciousness : conscious/alert
Speech normal
No neck stiffness
No kernigs sign
Cranial nerves-normal
8.REFLEXES:
Normal
9.CEREBELLAR SIGNS:
Finger nose co ordination: present
Knee heal co ordination :present
PROVISIONAL DIAGNOSIS:
INVESTIGATIONS:
