Gm case 4

6th march
Case Scenario.....
Hi,I am G.Amulya,3rd BDS student.This is an online eblog book to discuss our patients health data after taking his consent.this also reflux my patient centered online learning portfolio
                           CASE HISTORY
Patient detail
A 60 years old female occupation housewife,resident of mungodu presented with
CHIEF COMPLIANT
Abdomen pain since 5 days
Dry cough since4 days
Chest pain since4 days
Shortness of breadth since 2 days
HISTORY OF PRESENT ILLNESS
Patient is apparently asymptomatic,5 days back she got severe abdomen pain on her left hypochondrium region 
Dry cough since 3days which is incidious onset, gradually progressive in nature associated with chest pain
Shortness of breadth since 2 days grade ll to grade lll  
No aggrevating and relieving factors
Pedal edema is observed which is on and off
HISTORY OF PAST ILLNESS
Known patient of CKD
Not known complaints of asthama, tuberculosis
Not known patient of diabetic and hypertension
FAMILY HISTORY
No similar complaints
PERSONAL HISTORY
Diet- mixed
Appetite-normal
Bowel/ Bladder- regular
Sleep-adequate
GENERAL EXAMINATION
Patient is moderately built and moderately nourished
Conscious,non cooperative
Pallor-present
Icterus-absent
Cyanosis-absent
Clubbing-absent
Lymphadenopathy-absent
Edema- pedal edema 


  ----- PROVISIONAL DIAGNOSIS----- 
          Any pneumonia or lung infection
Q/A
Did the patient may effected by the present and previous medication?
 Does Past history of CKD may cause any complications?

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