GM case - 5

GM Case:5

March 10,2023
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 60 years old male, resident of Peddagutta, came with
Chief complaint: fever since 6 days along with abdominal pain and shortness of breath and cough since 2 days.

HISTORY OF PRESENT ILLNESS: patient is asymptomatic 1 week back and then developed fever with chills. The fever is more in the morning and decreased in the evening and associated with pain in the abdomen. The shoulder pain radiating downwards. Burning micturition and burning feet since 6 days.

HISTORY OF PAST ILLNESS:
Diabetes: No
Hypertension: No
Heart surgery: No
Asthma: No
Tuberculosis: No
Other surgeries: No

PERSONAL HISTORY:
Patient is conscious, cooperative and coherent

Occupation:
Diet: Mixed
Appetite: Normal
Bowl and bladder: Regular but burning micturition
Sleep: Normal
Allergies: No
Addictions: smokes chutta since 40 years(2 per day)

FAMILY HISTORY: NIL

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

Vitals:
BP: 130/70 mm Hg
Pulse rate: 78 bpm

Diagnosis: Pneumonia

Questions:
1. Will i recover after taking my medications?
2. How can I prevent this from happening again? 

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