GM CASE 3

GM Case 3

Case scenario.....

Hi, this is K.Shravan theja, 3 rd BDS student. This is an online eblog book to discuss our

patient's health data after taking his consent. This also reflects my patient centered online

learning portfolio.

*CASE SHEET:

Bresthelessness since 2 days.

*HISTORY OF PRESENT ILLNESS:

Patient was asympotomatic for 2 years.

Then she was diagnosed with hypertension.

She is under medication.

She had grade 1 breathlessness which was relieved on rest.

10 days back the breathlessness progressed from grade 2 to grade 3.

Then she visited hospital there she was diagnosed with heart failure , pleural effusion,

cardiomegaly.

There is no symptom of fever, cough, vomiting

*HISTORY OF PAST ILLNESS:

No history of diabetes, epilepsy, CAD, tuberculosis, asthma.

*FAMILY HISTORY:

There is no similar complaint.

*PERSONAL HISTORY:

married

Occupation: house wife

Appetite: normal

Diet: Non- vegetarian

Bowel: regular

Allergy: no

Addiction: smoking 10 per day

Alcohol once is 15 days

*GENERAL EXAMINATION:

Pallor: no

Icterus: no

Cyanosis: no

Clubbing: no

Lymphyadenopathy: no

*PROVISIONAL DIAGNOSIS: Pleural effusion

*Question from patient:-

*Does this Breathlessness get any worse?

What is the medication?

Questions from myside:

*Is hypertension in anyway related to plueral effusion?

*can pleural effusion get any worse?