GENERAL MEDICINE



GENERAL MEDICINE 

GM CASE 2

Saturday, March 4th 2023


March 4th 2023

CASE Scenario.....

Hi ,I am S.Aishwarya, 3rd bds student.This is an online elog book to discuss our patient health data after taking her consent. This also reflects my patient centered online learning portfolio.
                      
                  CASE HISTORY
Patient details
A 65 years old female occupation by farmer Resident of Rammanpet presented with the
Chief complaint of
Pain near the chest region since 3 days and shortness of breathe since 3 days.
History of present illness
Patient was apparently Asymptomatic 10 days back and then had severe pain in left  loin region which is radiated towards chest region and aggrievated while doing farming work.
History Past illness 
15 years back ,she noticed a swelling over the right foot and went to hospital then she was diagnosed with type 2 diabetes mellitus and from then she was on regular oral hypoglycemic medication [OHA].
No hypertension
No asthma
No tuberculosis
No CVA
No epilepsy
Personal history
Occupation : farmer
Appetite :normal
Diet: Mixed diet 
Sleep:Normal
Micturion : Normal
Bowels:Regular 

Family history 
Not significant...

General examination
Built :normal
Conscious and cooperative
Pallor : pale 
Icterus:no
Cludding:no
Lymphadenopathy: no
Edema: present ,non pitting
Cyanosis: no
Drug history
vitals
Real time ultrasonography
Temperature :98.7 degree Fahrenheit
Pulse rate:101/min
Blood pressure:120/60mm of Hg
Spo2:96%
Radiograph:
               provisional diagnosis 
                ------Kidney problem-----

Q/A
1) Is it curable on regular medication?
2)what kind of diet should I follow?


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