GM case - 1

GM Case:1 

March 02,2023
Case scenario..

Hi, I am S.Sharvani, 3rd year dental student. This is online elog book to discuss our patient health data after taking her consent. This also reflects my patient centered online learning portfolio. 

CASE SHEET:A 65 years old women, resident of Suryapet, came with
Chief complaint: burning sensation and pain during micturition since 2 months associated with abdominal pain 

HISTORY OF PRESENT ILLNESS: patient is apparently asymptomatic 2 months ago and then she had burning sensation during micturition and decreased output of urine associated with pain in abdomen since 2 months and there is increased pain in abdomen and heaviness in chest after intake of food, swelling of both lower limbs which are pitting type. 

HISTORY OF PAST ILLNESS:
Diabetic: 7 years using Gliclazide 5mg 
Hypertension: 7 years using Telma 40 mg
Heart surgery(angioplasty): done 7 years ago
Asthma: No
Tuberculosis: No
Diabetes and hypertension were diagnosed when she went for heart surgery. 

PERSONAL HISTORY: 
Patient is married
Occupation: Housewife
Diet: Mixed diet
Appetite: Irregular
Bowl and bladder: Irregular and burning sensation 
during micturition 
Sleep: Trouble falling asleep but sleeping under medication
Allergies: No
Addictions: Smoked for 10-15 years and stopped 10 years ago

FAMILY HISTORY: NIL

General examination:
Patient is conscious
Pallor: No
Icterus: No
Cyanosis: No
Clubbing of fingers or toes: No
Malnutrition: No
Dehydration: No
Lymphadenopathy: No
Edema of feet: Yes


Vitals:
BP: 130/70 mm Hg
Respiration: 18/min
Pulse rate: 80 bpm/min

Definitive Diagnosis: Urinary Tract Infection
Culture report- Escherichia coli >10,000 CFU/ml
Questions:
1. Will i recover after taking my medications? 
2. Is there any possibility of getting infected again?

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