GM CASE 3

GM case 3 
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 65 year old women joined with burning micturation and abdominal pain.

Chief complain : patient with burning micturation and abdominal pain since 2 months.

History of present illness:
Patient was apparently asymptomatic before 2 months.
She consultanted doctor and there were no symptoms diagnosed by that doctor. It have been 2 months after consulting doctor and burning sensation and pain haven't decreased. 
Swellings are present on hands , legs and face .
Signs of paralysis is found on face .

Associated diseases:
Diabetes mellitus type II
Hypertension

History of past illness:
Patient got heart stroke before 7 years.
And it was treated by stunt.
Patient is suffering from diabetes mellitus since 7 years.
Patient is suffering from hypertension since 7 years.
Before 2 years she got a paralysis attack . 
She have fatigue and there is a shooting type of nerve pain.
Stomach has swollen .
Personal History:
  Daily routine- She used to wake up around 6am,have breakfast around 9am. She used to have lunch at 1pm and would take rest for sometime and have dinner around 8pm.
     Appetite: no appetite since heart stroke.
     Diet: mixed
     Bowel movements: not regular 
      Addictions : no addictions 
     Micturition: burning micturation 
     Know allergies: no allergies 

Family History:
      No significant family history .

GENERAL EXAMINATION:
Pallor : no
Icterus :no
Cyanosis : no
Clubbing : no
Lymphadenopathy : no
Edema : no

VITALS:
Temperature: 98.6°c/f
Pulse: 69beats per minute
Respiratory rate: 16cycles per minute
Blood pressure: 130/90 mm of Hg
SPO2: 98%

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:


Questions from patient :
1. How I have to bare the acidity?
2. Medication required to increase appetite.

Questions from me:
1.Why did the signs of paralysis still present ?



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