GM Case - 3

 

 March 4,2023.

Case scenario..

Hi, I am Pranavi Sripada, student of BDS - III. This is an online elog book to discuss our patient’s health data after taking his/her consent. This also reflects my patient centered online learning portfolio.

CASE SHEET

A 65 year old female, resident of Konugodu has presented with

Chief complaint:

Shortness of breath , chest pain , swelling of face & legs since 10 days.

History of Present illness:

The patient was apparently asymptomatic 

2 years before

She went to a hospital with NYHA grade-1 shortness of breath with no associated fever,sweating & pain. There she was diagnosed hypertension.

10days back

She complaints of breathlessness which is gradual in onset , progressive from grade - II to grade - III associated with chest pain radiating to the left side of the neck & left shoulder & left arm and She was having swelling of her face & feet.

History of past illness:

Hypertension since 2 yrs 

(On medication tab.atenolol 50mg + tab.amlog 50mg)

Non-diabetic 

No Asthma 

No thyroid disorders 

Family History:

Nil

Patient History :

Diet - Mixed

Appetite - Normal

Bowel & Bladder - Regular

Sleep - Adequate 

Drug History :

Tab.ecosprin gold

Tab. Telma 40mg

Tab. Met-XL 25mg

General Examination:

Pallor - No

Icterus - No

Cyanosis - No

Clubbing - No

Lymphadenopathy - No

Oedema - No

Provisional diagnosis :

Right heart failure