General Medicine case-1

Case scenario...

Hii this is E.Bhargavi,3rdBDS student.This is an online eblog book to discuss our patients health data after taking his consent . This is reflects my patient centered online learning portfolio.

CASE SHEET:
A 30 year old men with leg injury 

Chief complaint:
Scooty skid at malareddygudem at 5:30pm

Present Health illness:
Yesterday he took an injection at govt hsptl after that he relived the pain but today morning onwards he felling the pain 


Past history:
Not diabetic No Hypertension No seizure No allergy 

Personal History:
Occupation:lorry driver
Appetite:lost
Diet:mixed
Bowel: regular

General Examination:
Pallor:No
Icterus:No
Cyanosis:No
Clubbing:No
Lymphadenopathy:No
Edema:No
Vitals:
 Pulse:72beats per minute 
Blood pressure:140/90
SPO2:98%

SYSTEMIC EXAMINATION:
Cardiac Vascular system:
Cardiac sounds: S1 S2 normal
Cardiac Murmur:No murmur
No thrils 
P/a soft no tender

Addictions: 
Alcoholic from past 2years 
Tobacco taking from past 2yrs
 
Diagnosis:
Abrasin right knee secondary to rta 
Medication:
Grbs 160mg %
Pan for 10 days 
Taxmin 200mg
Vit c for 10days 




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