GM CASE 3
60 YRS WITH SOB
10th March 2023
Case scenario......
Hi, This is M sindhuja, 3rd 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.
Case Sheet:
CHIEF COMPLAINTS AND DIRATION:
Patient c/o cough duration:1 week back.
Shortness of breath:1 week back
Fever with chills and rigor on and off since 1 week.
HISTORY OF PRESENT ILLNESS(HOPI):
Patient was apparently asymptomatic until 1 week. Then developed cough with sputum ( mucous, whitish in color, non foul-smelling, non blood stained, aggrevated during night, seasonal variation. Releived with medication.
Breathlessness/dysponea with grade 2 mmrs, aggrevated Associated with cough. More in supine position, no releiving factors.
Fever with chills and rigor low grade on and off 1 week back.
HISTORY OF PAST HISTORY:
No h/o chest pain, chest tightness, palpitation.
No h/o TB, loss of weight, loss of appetite.
k/c/o DM with medication of metformin 500mg, glimeperide 5mg 5 yrs back.
k/c/o burning micturation 4 days back.
h/o cough, shortness of breath 5 yrs back. Relieved with medication.
PERSONAL HISTORY
60yrs old patient f/c occupation of farmer resident of bhongiri.
Patient has normal appetite, mixed diet, regular bowls, and has burning micturation 4 days, has allergies.
No addiction to alcohol, tobacco.
FAMILY HISTORY:
Not significant.
EXAMINATION
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative.
Patient has no pallor/cynosis/icterus/lymphadenoathy/malnutrition/dehydration/clubbing/oedema.
VITALS:
Temperature : 98.7
Pulse rate :110bpm/min
Respiratory rate : 22cpm
Bp: 130/70mmHg
Spo2:97%
GRBS:307mg%
SYSTEMIC EXAMINTION
RESPIRATORY SYSTEM
URT:
Normal, No polyps.
Oral cavity is normal, oral hygiene.
LRT:
INSPECTION:
Shape of chest:symmentry,elliptical.
Trachea:appear central
Chest movement are equal in both sides
No supra/infraclavicular hallowing
Apex beating us not seen
No crowding of ribs
No drooping of shoulders
No cyphosis
No sinus, drainage.
PALPATION
No local rise in temperature
No tenderness
Trachea is central
PROVISIONAL DIAGNOSIS
EXACERBATION OF COPD WITH DM.
INVESTIGATION:
