GM case-2

CASE scenario....

Hi, I am D.Rajashri, 3rd BDS student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolio.

                 CASE HISTORY

Patient Details
A 70 year old male,farmer by occupation,resident of chityala presented with
Chief Complaint
Shortness of breath
Fever since 15 days
Headache 
History of present illness
*Patient was suffering with shortness of breath since 15 days which was present with farm work started insidiously,progressing over time,non seasonal, reached present state of shortness of breath at rest.
*Complaint of high grade fever and it subsided with medication for 1 week but from then he is having intermittent fever
*Complaint of headache, intermittent,throbbing type, diffuse and bilateral.not associated with nausea , vomitings.
Past history
*Known case of diabetes since 10 years
*Not a known case of hypertension, epilepsy,CAD
*No history of TB in the past
*History of similar complaints in the past, 6 months back, which was relieved by medication
Family history
*No history of similar complaints in the family
Personal history
Patient takes mixed diet but has increased appetite
Sufficient sleep
Bowel and bladder -normal
Urine colour- orange
Occasional alcoholic
Stopped smoking one year back
General Examination
Patient was unconscious and thin built and nourished 
Pallor present
Edema absent
Vitals
Pulse Rate-87 bpm
Respiratory Rate-21cpm
Blood pressure -100/60 mm Hg
SPO2- 97%
Q/A
*What is the cause for orange colour of urine?
*Is there any infection in the kidney
*Can this be treated by taking antibiotics
*Is shortness of breath is due to pneumonia 

All the above information is been given by the patient's wife named kethamma as the patient was unconscious.


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