GM CASE 9

GM Case 9

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:-

•A 32 year old Male who as suffering from Abdominal pain and fever since 7 days and burning micturition since 3 days.

*HISTORY of PRESENT I'LLNESS:-

•Patient was Asymptomatic since 1 week ago.

•Since 1 week,he was suffering from abdominal pain.

•The pain is pricking type of pain,continous,agrevated on inspiration.

•The pain is in left illiac to right illiac.

•Fever since 7 days,ON and OF, which is relieved on taking inspiration.

•Dry cough since 1 day,ON and OF,which is relieved on taking inspiration.

•Burning micturition is present,no frequency and no urgency.

•No vomiting, shortness of breath, palpitation.

•Body pains,head ache since 6 days,which is generalised weakness.

•Headache is continous.

*HISTORY OF PAST ILLNESS:-

•No Diabetesmellitus,Hypertension,CAD,

Epilepsy, Asthama & TB.

*FAMILY HISTORY:-

•No significant complaints.

*PERSONAL HISTORY:-

•Married

•Occupation:Farmer

•Appetite:Normal

•Diet:Mixed

•Bowel: Regular 

•Allergy:No

•Addiction: •Alcohol (Once in 4 days (90ml) )

                    •Pan masala 

*GENERAL EXAMINATION:-

•Pallor:-No

•Icterus:-No

•Cyanosis:-No

•Clubbing:-No

•Lymphadenopathy:-No

*SYSTEMIC EXAMINATION:-

*INSPECTION:-

*Upper Respiratory track:-

•Oral hygine:-Stains, Gingival recession 

•Oropharynx:-Normal

•Chest appearance:-Elliptical in shape

•Respiratory movement:-Equal on both the bilateral sides

•Trachea position:-Central in position

•Dilated veins:-No

•Scars:-No

•Sinuses:-No

•Visible pulsation:-No

•Drooping:-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:-

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•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