SOB [II/III], Fever, Generalised body pains (36 year old woman) GM - CASE 3
22nd August 2022
CASE STUDY 3
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
- shortness of breath [grade II/III]
- headache since 4 days
- fever and chills since 4 days
- generalised body pains since 4 days.
HISTORY OF PRESENT ILLNESS:
Shortness of breath since 14-16 hours.
ASSOCIATED DISEASES:
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PAST HISTORY:
h/o Masectomy on left side 1½ year back.
Renal calculi 1 year back.
N/K/C/O HTN, DM, Thyroid disorder, CAD, TB, Epilepsy.
K/C/O Renal failure since 3 years.
PERSONAL HISTORY:
Regular Bowel movements.
Has normal micturition with no burning sensation.
Has no known allergies.
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 - 102°
-GRBS - 86
VITALS:
Temperature: Afebrile
Pulse: 116 beats per minute
Respiratory rate: 26 cycles per minute
Blood pressure: 100/70 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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