General medicine

February 26, 2023

GM case 1

Case scenario.....

Hi, this is B.Tejaswini , IIIrd BDS. This is an online eblog book discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.

 CASESHEET:a 85 year old women has come to hospital in an unresponsive state. 

Chief complaints: fever  and chills since past 10days,burning Micturition and pain in the abdomen, vomitings, and also not taking fuilds or liquids since 2 days. 

HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic before 1month.

Since 1 month  the patient is suffering from mild joint pain. And then the patient was suffering from fever and abdominal pain since 10 days, and  loss of appetite  I.e. not taking any fluids or liquids from last 2 days.

Suddenly the patient was unconscious and was not talking to anyone.

Associated diseases:

Hypotension 

Gastric acidity.

 

History of past illness:

The patient has taken an gall bladder removal surgery(cholecystectomy) before 10 years.

PERSONAL HISTORY: 

Appetite : decreased 

Diet: vegetarian 

Bowel and bladder movements: irregular 

Addictions : Nil

Micturition: normal

Known Allergies : nil

FAMILY HISTORY: 

Not significant 

GENERAL EXAMINATION:

Pallor : no

Icterus :no

Cyanosis : no

Clubbing : no

Lymphadenopathy : no

Edema : no

VITALS:

Temperature: 98.6°c/f

Pulse: 88 beats per minute

Respiratory rate: 15 cycles per minute

Blood pressure: 111/50 mm of Hg

SPO2: 100%

SYSTEMIC EXAMINATION:

The patient has became very thin and is 

Not responding .

Oral cavity- normal oral hygiene.

  Cardiovascular Examination:

Thrills: no

Cardiac sounds: S1, S2 heard

Cardiac murmurs: No

PROVISIONAL DIAGNOSIS:

Uremic encephalopathy 

Moderate Lv dysfunction. 

Questions from patient :

Will she become normal again? 

                                 ( from their relatives)