GENERAL MEDICINE
Gm case - 4
April 4, 2023
General Medicine
Case 4
Case scenario....
Hi, I am B.pragathi , 3rd BDS student.
This is an online elog book to discuss our patient health data after taking his consent. This also reflects my patient centered online learning portfolio .
CASE HISTORY
Patient details
A 60 years old female, named lingamma, occupation by farmer, Resident of monugodu presented with the
Chief complaints of
Dry cough , shortness of breath, chest pain, fever, decreased urine output since one week.
History of present illness
Patient was apparently asymptomatic one week back.then she started complaining of dry cough since a week. Associated with chest pain, shortness of breath since a week. Which is insidious onset And gradually progressive in nature and it is grade- 3( shortness of breath on doing less the ordinary activity) she also complained of decreased urine output ( oliguria) since a week .
History of past illness
Hypertension: No
Tuberculosis: No
CVA : No
Epilepsy: No
Diabetes: No
Family history
Not significant
Personal history
Diet:mixed
Appetite: Normal
Micturition: low output (oliguria)
Bowel movements: Normal
Addictions: No
Sleep: Normal
General examination
Patient was conscious and Co-operative .
Normal built
Moderately nourished
Pallor: No
Icterus: No
Cyanosis: No
Clubbing: No
Lymphadenopathy: No
Edema: pedal edema
PROVISIONAL DIAGNOSIS
Renal failure
Q/ A
1. How can I reduce my risk of complications ?
2.which diet should I follow ?
3.How many episodes of dialysis should I need?
