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GENERAL MEDICINE MONTHLY ASSIGNMENT (JUNE 2021)

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  Case History and Clinical Findings 74 YEAR OLD FEMALE PATIENT WAS BOUGHT TO CASUALITY WITH GENERALISED WEAKNESS SINCE 3 DAYS HOPI: PATIENT WAS APPARENTLY ALRIGHT 3 DAYS BACK TODAY PATIENT ATTENDER SAW HER ON THE FLOOR WITH HER CLOTHES STAINED WITH FAECES AND MICTURTION NO FOOD INTAKE SINCE LAST 3 DAYS NO C/O CHEST PAIN , FEVER , SOB , PALPITATIONS NO VOMITINGS , LOOSE STOOLS SHE IS ABLE TO LIFT HER HANDS AND LEGS PAST HISTORY : N/K/C/O HTN , DM 2 , THYROID DISORDERS , CVA , CAD PERSONAL HISTORY: MIXED DIET APPETITE LOST BOWEL AND BLADDER - REGULAR ADDICTION : REGULAR 180 ML DAILY ALCOHOL CONSUMPTION SINCE 10 YEARS GENERAL EXAMINATION: PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE NO SIGNS OF PALLOR,ICTERUS,CLUBBING,CYANOSIS ,LYMPHADENOPATHY,EDEMA VITALSTEMP- 99.9 F PR- 124 BP RR-22 CPM BP-120/70MMHG SPO2- 99% AT RA CVS- S1,S2 HEARD , NO MURMERS RS- BLAE PRESENT , NO ADDED SOUNDS P/A- SOFT, NON TENDER NO ORGANOMEGALY CNS- RIGHT LEFT TONE : UL N N LL N N POWER : UL 4/5 4/5 LL 4/5 ...

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