Decreased Appetite, Repeated Emesis on eating, Fever, SOB (54 year old woman) CASE - 2
18th August 2022
CASE STUDY 2
Hello, I am Saloni .S. Gangotri , a 3rd 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 SHEET:
CHIEF COMPLAINTS:
c/o
- decreased appetite since the past 3 days.
- shortness of breath
- vomiting since 2 days everytime she eats anything.
- fever since 6 days.
HISTORY OF PRESENT ILLNESS:
54 year old female came to department with c/o decreased appetite since 6-7 days and also vomiting since 6-7 days everytime she eats anything with all the contents.
She also complains of fever since the past 7 days intermittently which is relieved on medication.
Shortness of breath since 3 days on sitting upright.
ASSOCIATED DISEASES:
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PAST HISTORY:
h/o Type 2 Diabetes Mellitus since 30 years (through medical checkup)
On insulin injections since 10 years.
Has HTN and is on medication for same since 20 years.
K/C/O Renal failure since 3 years.
PERSONAL HISTORY:
Lost appetite with Regular Bowel movements.
Has normal micturition with no burning sensation.
Has no known allergies.
Consumes Betel Leaf (Pan).
FAMILY HISTORY:
Has no history of Diabetes Mellitus, No HTN, No Cardiac Strokes, No cancers.
DRUG HISTORY:
GENERAL EXAMINATION:
-palor present
-No cyanosis
-No lymphadenopathy
-No icterus
-No edema of feet
-No clubbing of fingers
-Temp - Afebrile
-GRBS -
VITALS:
Temperature: Afebrile
Pulse: 87 beats per minute
Respiratory rate: 20 cycles per minute
Blood pressure: 130/80 mm of Hg
SPO²: 98
SYSTEMIC EXAMINATION:
Cardiovascular system:
No thrills
No murumurs
Cardiac sounds: S1, S2 present
Respiratory system:
No dyspnea
No wheezing
Breath sounds heard: vesicular? yes
Abdomen:
Shape : Regular
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard
Central Nervous System:
Conscious and Alert
Speech: Normal
INVESTIGATIONS:
Biochemical investigations:
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2D ECHO REPORT
ULTRASOUND REPORT:
GRAPHIC SHEET:
PROVISIONAL DIAGNOSIS:
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