GENERAL MEDICINE

GM- CASE 5

Tuesday, 1 August 2023

1 August 2023
CASE scenario....

Hi, I am k.saimadhuri 3rd year 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 : A 54year old known case of abdominal bloating 
CHIEF COMPLAINTS : abdominal bloating since 15 days, and breathlessness since 15 days 

HISTORY OF PRESENT ILLNESS : 
Patient was apparently asymptomatic  15 days  ago,then abdominal bloating started ,it aggrevates after taking food and reliving on medication. Breathlessness since 15days breath less ness on exertion of grade 1 MMR then gradually progressed to grade 2 aggrevated during abdominal bloating . Trauma to left 8th rib before 3 days while doing his work  it is painfull and the pain is of dragging type and it is continues and aggravates on moving and deep inspiration. 

PAST ILLNESS :
Not a know case of diabetes, hypertension 
 Not known case of renal failure 

PERSONAL HISTORY : 
Mixed diet, apatite is normal, have proper sleep, regular bowel, alcoholic since 10 years daily 90 ml ,and bede smoking since 10 years daily 10 bedes.

FAMILY HISTORY : 
Not significant 
GENERAL EXAMNLINATION : 
Built : moderately built
Nourishment : moderately nourished
Consciousness: in Conscious
Pallor : no 
Icterus : no 
Cyanosis : no cyanosis 
Clubbing : no clubbing 
Lymphadinopathy : no lymphadenopathy 
Edema : no edema
Systemic examination:
Inspection,  all teeth are affected by caries, and has stains ,
Flanks are full , distention  umbilicus is central and inverted 
No surgical scar, no dilated veins ,no pulsations 
Palpation, 
No tenderness or local rise of temperature 
Abdomen is hard ,lower border of liver not palpable ,spleen not palpable, fluid thrill absent  
Percussion 
Liver upper border of liver dullness in 5th intercostal  space lower  border could not be appreciated 
Auscultation
Normal bowel sounds heard 
 Diagnosis:  acid peptic disease,  8th rib fracture. 

     

Popular posts from this blog

GENERAL MEDICINE

GM- CASE  Tuesday, 11 April 2023 11 April 2023 CASE scenario.... Hi, I am k.saimadhuri 3rd year bds student. This is an online elog book to discuss our patients health data after taking her consent. This also reflects my patient centered online learning portfolio. CASE HISTORY : A 45 year old known case of joint pains  CHIEF COMPLAINTS : joint pains (wrist,ankle,neck back) from 4 years HISTORY OF PRESENT ILLNESS :  Patient was apparently asymptomatic  4 years ago,then joint pain started ,it is at wrist,ankle,neck back, tingling like sensation, at ankle it is non radiating, at wrist it is non radiating and at neck back it is radiating bilaterally to shoulder, their is no progression in pain , aggravates on doing work and during morning ,releaved on medication  PAST ILLNESS : Known case hypertension from 20 years on medication  Not a know case of diabetes, Known case of renal failure PERSONAL HISTORY :  Mixed diet, appetite is normal, have proper sleep, regular bowel, drinks toddy ,stopp
Read more

GENERAL MEDICINE

GM- CASE 2 Tuesday, 7 march 2023 7 march 2023 CASE scenario.... Hi, I am k. Sai madhuri 3rd year 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 : A 51 year old known case of fever. CHIEF COMPLAINTS : fever and , foot injure from 20 days HISTORY OF PRESENT ILLNESS :  Patient was apparently asymptomatic 20 days back,then he had injury while doing his work .It was not healing,then followed by fever since 15 days,it is intermittent associated  with pain relieve on medication.  PAST ILLNESS : 7 years back he diagnosed with diabetes on his regular check up  and 5 year back he diagnosed with hypertension on regular check up and  he was on regular medication  He is taking insulin subcutaneously before every meal  PERSONAL HISTORY :  Mixed diet,apatite normal, have proper sleep, regular bowel and micturition.  FAMILY HISTORY :  Diabetes : present  His father  ha
Read more