GM CASE -2

Case scenario...

Hi,I am G.Manogna,3rd BDS student.This is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio 

                 CASE HISTORY 
Patient Details 
A. 65 year old female occupation:labourer resident of Nalgonda presented with
Cheif complaints
Breathlessness -since 1 month
Cough
Cold
Decrease in urine out and stool output -since 1 month
History of present illness
*Apparently patient was symptomatic since 5  months initially grade 1 to grade 2 since February 3rd breathlessness increased visited nearby hospital and took medicines. Further she is diagnosed with facial puffiness and pedal oedema due to drug side effects.
*She has loss of appetite since one month.
*Patient came with decreased urine output and stool output .
History of past illness
Asthma is present
Diabetic 
Hypertension is present
No tuberculosis
No epilepsy 
Family history
No similar complaints 
Personal history
Diet-non vegetarian
Appetite -loss of appetite
Sleep -inadequate
Bowel/bladder-irregular
General examination
Level of consciousness:Drowsy
Pallor: absent 
Icterous:absent
Cyanosis:absent
Clubbing:absent
Pedal edema was present but cured after the treatment
Vitals
Temperature:98.2 F 
Blood pressure:120/80 mm  of Hg
Pulse rate:86 beats per minute
Respiratory rate:25 cycles per minute
SPO2:88%
Cardiovascular examination
Thrills:No
Cardiac sounds :S1,S2 heard
Drug history

ATTENDERS SIGN
  
------ Provisional diagnosis: chronic obstructive pulmonary disease ------
  
Questions:
How long does it take for her to discharge?
Can she be able to do her daily course activities by her own?


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