GM CASE 8

GM Case 8

Case scenario.....

Hi, this is K.Shravan theja, 3 rd BDS student. This is an online eblog book to discuss our

patient's health data after taking his consent. This also reflects my patient centered online

learning portfolio.

*Case sheet:-

*Cheif complaint:-

•A 38 year old Male patient is suffering from burning sensation in chest region since 1 year.

•Abdominal pain and  burning micturition since 6 months and pain in the hip region sicne 3 days.

*HISTORY of PRESENT I'LLNESS:-

•Patient was apparently asymptomatic 1 year back.

•Then he had burning sensation in epigastric region,which is progressive aggregated after taking with food and relived after 2 to 3 hours.

•It is associated with abdominal pain which is twisting pain (continuous) since 6 months.

•Burning micturition since 6 months and no increasing and decreasing urine output.

•Left hand pain since 3 days (Dragging type) radiating to left leg.

*HISTORY OF PAST ILLNESS:-

•No Diabetes mellitus,Heart attacks,CAD, Asthama,TB and Palpitations.

*FAMILY HISTORY:-

•No similar complaints.

*PERSONAL HISTORY:-

•Occupation:Farmer

•Appetite:Normal

•Diet:Mixed

•Bowel:Normal

•Allergy:No

•Addiction: Alcoholic (since 10 years)

*GENERAL EXAMINATION:-

•Pallor:-No

•Icterus:-No

•Cyanosis:-No

•Clubbing:-No

•Lymphadenopathy:-No

*SYSTEMIC EXAMINATION:-

*INSPECTION:-

*ORAL:- 

•Oral hygine:-Poor

•Caries:- Present

•Gum hypertrophy:-No

•Pharyngeal deposite:- No

•Post nasal drip:-No

*ABDOMINAL:-

•Shape:-Scaphoid

•Planks:- Full

•Umblicus:- central/Inverted

•Sinuses:-No

•Scratches:-No

•Striae:-No

•Punctures marks:-No

•Dilated veins:- visible in moment of abdominal wall

*PALPATION:-

•No local rise of temperature.

•Superficial:- Tender,No palpable mass.

•Deep:-liver:- No palpable/ non tender.

          Splee:-No palpable / non tender.

*PERCUSSION:-

•Liver span:-

•Fluid thrill:-Absent

•Shifting dulllness:-Absent

•Puddlis sign:-

*AUSCULTATION:-

•Bowel sound:- 7/Min