General Medicine E-log (5)

Hi, I am Danush Varkur, 3rd sem medical student.This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.

CASE SHEET:

Chief complaints:

A 26 year old female, hailing from nakerekal, agricultural worker by occupation, came with chief complaints of:
- generalised weakness since 15 days back
- fever 15 days back
- Shortness of breath since 6 days

History of present illness:

The patient was apparently asymptomatic 15 days back. She then developed generalised weakness during her routine work , which subsided on rest.

Then 15 days back, she developed fever, which was associated with chills and rigors at earling morning, which was subsided on medication with paracetamol and fever was recurring if medication was not taken.

10 days back, she then developed cough which was non productive cough, associated with left sided chest pain, which was not relieved on medication.

6 days back, she then developed Shortness of breath of ( grade III ), which was aggrevated on doing daily routine work. She also developed Shortness of breath after she woke up from bed which lasted for a few minutes.

She then developed night sweets, yesterday night.
No history of body pains, vomitings, headache, hemoptysis.

Past history:
No history of Diabetes mellitus, hypertension, thyroid disorders, epilepsy, coronary artery diseases.

Personal history:

Diet: Mixed
Bowel : regular
Micturition: normal
Appetite: decreased
Habits: nil
No history of allergy, asthma, tuberculosis, coronary artery disease.

Family history:
Insignificant

General examination:
Pallor present


No icterus
No cyanosis
No clubbing
No lymphadenopathy
No malnutrition
No dehydration
No pedal edema 

VITALS:

Temperature: 98.6 F

Pulse: 80 beats per minute, irregular

Respiratory rate: 16 cycles per minute

Blood pressure: 110/70 mm of Hg

SPO2: 96%

SYSTEMIC EXAMINATION:

Respiratory system:

Inspection:
Shape of chest: flat shape
Symmetry: hollow on supraclavicular region on right side
Respiratory movements: tachypnea
Rhythm: regular
Type: thoracoabdominal

Palpation:
Position of trachea: Central
Vocal fremitus: increased on left side
Tenderness: absent

Percussion:
Dullness on left side of the chest

Auscultation:
Breath sounds: vesicular
Intensity: reduced on left side
Additional sounds: wheeze is present

Cardiovascular system:

No thrills
murmurs: systolic murmur
Cardiac sounds: S1, S2 heard

Abdomen:

Shape of abdomen: scaphoid
No tenderness
No Palpable mass
Non palpable liver
No Palpable spleen
No bruits
Bowel sounds: heard

Central Nervous System:

Conscious
Speech: normal

Investigations:

Provisional Diagnosis:
Left upper lobe Pneumonia

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