CASE 10

*Case scenario.....

Hi, this is k.shravan theja, 3 rd BDS student. This is an online e-blog book to discuss our patient's health data after taking his consent. This also reflects my patient centered online learning portfolio.

*CASE SHEET:

•A 22-year-old female came with chief complaint of fever since 4 days.

*CHIEF COMPLAINT:

•Fever since 4 days.

•Headache since 4 days.

*HISTORY OF PRESENT ILLNESS:

•Patient is apparently asymptomatic 4 days ago.

•When she noticed fever since 4 days.

•Patient has intermittent, sudden onset, low grade fever which is relieved on medication.

•The fever is not associated with chills and no increase in temperature at night.

•Headache since 4 days.

•The pain is radiating from left to right.

•The pain is continuous, not relieved on medication.

•There is no vomiting and shortness of breath. 

*HISTORY OF PAST ILLNESS:

•No asthma, diabetes , hypertension, tuberculosis, epilepsy, cad

*FAMILY HISTORY:

•No similar compliment.

PERSONAL HISTORY:

•Diet - mixed

•Bowel and bladder- regular

•Sleep- adequate

•Appetite-regular

•Addiction- no

•Allergy: no

                   

*GENERAL EXAMINATION:

•Pallor: no

•Icterus: no

•Cyanosis: no

•Clubbing: no

•Lymphadenopathy: n0

•Edema : no

•Built: well built

•Nourishment: well nourished

•Pulses: Temperature: 102℃

•Blood pressure: 90/60 mm / hg

•pulse : 84

*SYSTEMIC EXAMINATION:-

 

*RESPIRATORY EXAMINATION:-

*INSPECTION;

•UPPPER RESPIRATORY TRACK: normal

•NASAT SEPTUM: in midline

•ORAL CAVITY: no stains , caries are seen

•OROPHARYNX: normal

•CHEST APPEARANCE: elliptical in shape

•RESPIRATORY MOVEMENTS: equal on both sides. 

•SYMMETRY: bilateral symmetry

•TRACHEA POISITION: in midline

•DILATED VEINS: no

•SCARS: no

•SINUSES: no

•VISIBLE PULSATION: no

•DROOPING: no

•PALPATION: 

•trachea is central in position 

•apical impulse is normal.

•Dilated vein: no

•Infra & supra scalloping: no

•Chest movements: equal on both sides during inspiration.

•Measurements: transverse : 25.5cm

•Anterio posterior: 20cm

•AP: T = 

Right lobe: 39cm

left lobe: 39cm

total chest: 78cm

*PERCUSSION:

•Resonant sounds are heard.

•No additional sounds are heard.

 *GIT:-

*INSPECTION

*UPPPER RESPIRATORY TRACK: normal

•NASAT SEPTUM: in midline

•ORAL CAVITY: no stains, no caries are seen.

•OROPHARYNX: normal

•UMBILICUS POSITION: Central inverted

•SHAPE : scalloped, equal on both sides. 

•FLANGS AND DISTENSION: no

•DILATED VEINS: no

•SCARS: no

•SINUSES: no

•VISIBLE PULSATION: no

•All quadrants are moving equally on inspiration

*PALPATION:

•There is local rise in temperature.

•Superficially, no palpable mass, no tenderness is seen.

•Deep, no palpable liver or spleen.

*PERCUSSION:

•No fluid thrills, shift in dullness

•no puddle's sign.

•liver- 7cm

*AUSCULTATION:

•Bowel sounds are heard.

*PROVISIONAL DIAGNOSIS:

•Generalized fever & weakness.