Gm case..

Case scenario...
Hi ,I am M.Sindhupriya 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
Case sheet: A 65 years old female resident of suryapet..
Chief complaints: 
- fever
- Shortness of breathe
- pain in right lower limbs
History of present illness:
- Patient was apparently asymptomatic 1 week ago she then had pain in right lower limb and right side of lower back..
- insidious in onset and gradually progressive ,
- Fever :low grade, intermittent and associated with chills and lightly relieved by medication.
-Sob: Grade 2 
-Also complaint of loss of appetite since 1 week.
-constipation since 3 days.
Negative findings:
- no pain in abdomen, no burning micturition,no chest pain.
History of past illness:
Not a  k/c/o DM,TB,Epilepsy,CVA,CAD,thyroid disorder..
Personal history:
-Married
- appetite:lost
- Diet : mixed
- Bowels :  constipation
- Micturition: Abnormal
- Known  allergies: no
Family history:
Not significant
General examination:
Patient is conscious, coherent,and co operative
-no pallor
- no icterus,
- no cyanosis
- no clubbing
- no lymphadenopathy
- no oedema
- no malnutrition
Vitals:
Temparature: 99.1 F
Pulse rate: 78/ min
Respiratory rate: 18/ min
Bp : 120/ 70
Spo2: 96
Grbs: 87 mg%
Systemic examination:
1.Cardiovascular system:
No thrills
Cardiac sounds S1,S2 heard
No cardiac murmurs
2.Respiratory system: 
No dyspnoea
No wheeze
Postion of trachea : Central
Breathe sounds: vesicular
3.Abdomen:
Shape of abdomen: scaphoid
Tenderness: no
Palpable mass: no
Bruits: no
Liver: not palpable
Spleen: not palpable
Bowel sounds: yes
4.CNS:
Patient was conscious
Speech : normal
Neck stiffness present.
Q/A:
What are the reasons for sob.
What are the other systems affected.
ECG:


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