GM case 2

Case scenario.....
Hi, this is k.vaishnavi , 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.

Case sheet: a 17 year old boy with cough.

Chief complain : cough since 13 days .
History of present illness : the patient was apparently asymptomatic before 13 days . From 13 days he is suffering from cough. From past 2 days cough is produced with sputum.
 
Associated diseases: no diseases.

History of past illness: no similar complain in past.

PERSONAL HISTORY: 
Appetite : Normal 
Diet: vegitarian 
Bowel and bladder movements: Regular 
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: 98.9°c/f
Pulse: 84beats per minute
Respiratory rate: 21cycles per minute
Blood pressure: 110/80 mm of Hg
SPO2: 97%

SYSTEMIC EXAMINATION:

Upper respiratory tract examination:
Left sided deviated nasal septum 
Oral cavity- normal oral hygiene 
Lower respiratory tract :
Inspection :
- shape of chest is symmetrical,elliptical 
- Chest expansion equal on both sides 
Palpation :

All inspectory findings are confirmed with palpation.
 Trachea central in position.
 No local rise in temperature
 No tenderness 
 Chest movements: Equal on both side.

  Cardiovascular Examination:
Thrills: no
Cardiac sounds: S1, S2 heard
Cardiac murmurs: No

PROVISIONAL DIAGNOSIS:
Sever cough
Questions from patient 
How long it takes for recovery ?
Why cough is persistent for such a long time ?
Questions from me 
While checking blood pressure patient showed flexion of his fingers , and calcium levels are normal why ?

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