GM CASE 8
GM Case 8
Case scenario.....
Hi, this is B. Meghana, 3 rd BDS student. This is an online e-blog 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 came with chief complaint of abdominal pain ,fever since 7 days and burning micturition since 3 days.
CHIEF COMPLAINT:
abdominal pain since 7 days
fever since 7 days
burning micturition since 3 days.
HISTORY OF PRESENT ILLNESS:
Patient is asymptomatic 7days ago.
since 1 week he is suffering from abdominal pain.
the pain is pricking type of pain, continuous, aggravated on inspiration.
The pain is in left iliac and right iliac region.
fever since 7 days, on and off, high grade , intermittent, associated with chills.
Dry cough since 1 day, on and off which is relieved on taking inspiration.
Burning sensation during micturition since 3 days, no frequency no urgency.
No vomiting, shortness of breath, palpitation, no nausea, no cold.
generalized weakness since 6 days.
HISTORY OF PAST ILLNESS:
He has no diabetes, no hypertension, CAD, tuberculosis, asthma.
FAMILY HISTORY: No similar complaint
PERSONAL HISTORY:
Occupation: farmer
Diet: mixed
Appetite: normal
Sleep : regular
Bowl and bladder: regular
Addiction: alcohol( once in 4 days 90 ml)
pan masala occasionally)
Allergy: no
GENERAL EXAMINATION
Pallor: no
Cyanosis: no
Icterus: no
Clubbing: no
Lymphadenopathy: no
Oedema: no
SYSTHEMIC EXAMINATION:
RESPIRATORY EXAMINATION
INSPECTION
UPPPER RESPIRATORY TRACK: normal
NASAT SEPTUM: in midline
ORAL CAVITY: stain, gingival recession are seen
OROPHARYNX: normal
CHEST APPEARANCE: elliptical in shape
RESPIRATORY MOVEMENTS: equal on both sides.
SYMMETRY: bilateral symmetry
TRACHEA POISITION: in midline
DILATED VEINS: no
SCARS: no
SINUSES: no
VISIBLE PULSATION: no
DROOPING: no
PALPATION:
trachea is central in position
apical impulse is normal
Measurements: transverse : 30cm
anterio posterior: 21cm
AP: T = 1.4
PERCUSSION:
Resonant sounds are heard.
GIT
INSPECTION
UPPPER RESPIRATORY TRACK: normal
NASAT SEPTUM: in midline
ORAL CAVITY: stain, gingival recession are seen
OROPHARYNX: normal
UMBILICUS POSITION: Central inverted
SHAPE : normal, equal on both sides.
FLANGS AND DISTENSION: no
DILATED VEINS: no
SCARS: no
SINUSES: no
VISIBLE PULSATION: no
All quadrants are moving equally on inspiration
PALPATION:
mild tenderness is seen in right iliac , right lumbar and left iliac.
liver and spleen are not palpable
PERCUSSION:
liver- 14.5cm
spleen dullness is noticed in left coastal region.
AUSCULTATION:
Bowel sounds are heard in right iliac region.
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