general medicine case-2

March,5 2023
March 4 2023

Case-2
March 4 2023

Hi,I am Y.Ashwitha 3rd sem dental student.This is online elog book to discuss our patient health data after taking her consent.This also reflects my patient centered online learning portfolio.
CASE SHEET:A 65 yrs old female with complaint of shortness of breath and dry cough .

CHIEF COMPLAINT:
Shortness of breath since 2 days,dry cough,
Asymptotic 2 years back had diagnosed as hypertension.
Had also have signs like oedema, constipation,decreased urine output.

HISTORY OF PRESENT ILLNESS:
She had no history of fever,cough,chills
She has lung infection, shortness of breath since February 3rd facial puffiness,pedal oedema.

HISTORY OF PAST ILLNESS:
The patient was apparently Asymptomatic 2 years back ,first sign as hypertension.

PERSONAL HISTORY:
Loss of appetite.
Small amounts of food taken.
Irregular bowel.
Micturation: abnormal
Addictions:smoking(chutta-30 years back),Toddy, whiskey- occasionally.

FAMILY HISTORY:
No diabetes,No thyroid,No hypertension, No heart diseases,No lung infections.

GENERAL EXAMINATION:
No parlor,
No lcterus,
No cyanosis,
No clubbing,
No oedema,
No lymphadenopath

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