GM CASE -04
31 October 2023
Chief Complaint :-
A 54 years old man come to OPD with cheif complaint of abdomin pain and discomfort since 2 months
History of present illness:-
Paitent was aparently asymptomatic before 2 months back.. Now he developed Abdominal bloating since 2 months..
Which is aggrevating on food intake
Relieving on medication..
Belching present
No regurgitation..
Shortness of breath which is of grade 3..since 2 months
Aggrevating on working And after bloating of abdomen
Relieving on sleep..
Negative history:-
No chest pain, palpations, orthopenia, decrease in urine out put..
History of Trauma to left 8th rib while he doing routine labour work and continuous pain in left chest side which is of dragging type of pain..
Aggrevating on movents and deep inspiration..
No history of fever, vomiting, loose stools
History of past illness:-
Diabetes:- no
Hypertension:- no
Asthma:- no
Tb:-no
Epilepsy:- no
Personal history:-
Diet:- mixed
Appetite:-normal
Sleep:- regular
Bowl and Bladder:- normal
Addiction:- daily 90ml in the evening
Smoking of bidi 10 bidis per day
Family history:-
No such relavent history..
General examinations:-
Patients is co operative and conscious
Bulit:- modrate
Nourishment:- well
Pallor:- no
Icterus:- no
Clubbing:- no
Cynosis:-no
Lympadenopathy:- no
Edema:no.
Hii this is E.Bhargavi,3rdBDS student.This is an online eblog book to discuss our patients health data after taking his consent . This is reflects my patient centered online learning portfolios
Chief Complaint :-
A 54 years old man come to OPD with cheif complaint of abdomin pain and discomfort since 2 months
History of present illness:-
Paitent was aparently asymptomatic before 2 months back.. Now he developed Abdominal bloating since 2 months..
Which is aggrevating on food intake
Relieving on medication..
Belching present
No regurgitation..
Shortness of breath which is of grade 3..since 2 months
Aggrevating on working And after bloating of abdomen
Relieving on sleep..
Negative history:-
No chest pain, palpations, orthopenia, decrease in urine out put..
History of Trauma to left 8th rib while he doing routine labour work and continuous pain in left chest side which is of dragging type of pain..
Aggrevating on movents and deep inspiration..
No history of fever, vomiting, loose stools
History of past illness:-
Diabetes:- no
Hypertension:- no
Asthma:- no
Tb:-no
Epilepsy:- no
Personal history:-
Diet:- mixed
Appetite:-normal
Sleep:- regular
Bowl and Bladder:- normal
Addiction:- daily 90ml in the evening
Smoking of bidi 10 bidis per day
Family history:-
No such relavent history..
General examinations:-
Patients is co operative and conscious
Bulit:- modrate
Nourishment:- well
Pallor:- no
Icterus:- no
Clubbing:- no
Cynosis:-no
Lympadenopathy:- no
Edema:no.
Systemic examination:-
Respiratory system:-
Inspection:-
Upper respiratory tract:- oral hygiene not good
caries present
stains present
No haltolis
No nasal septum deviation
No sinus tenderness
No tonsils
Lower respiratory tract:-
Chest is symmetrical
No drooping of shouler
Trachea midline
No suprascapylar and intrescapular hallowong
No pectus carnitum, no pecrus escavum and kphyscolisis
Palpation:-
Inspectory finding are conformed in palpation
Superficial
Rise in temperature
Trachea midline
No drooping of shoulder
Transverse 50
Anteriposterior30
Thoracic circumference 80
Semi thoracic 40
Percussion:-
Clavicular supra and inta
Mammilary
Auxiliary infra and supra
Suprascapular and infrascapular
All resonate sounds heared
Auscultation
Vesicular breath sounds 16 / min.
Vitals:-
Bp:- 120/80
Temperature;- 97.4
Pulse:- 75 per min
Investigation:-
Hemogram
Hb:-13.4
RBS:-97mg/dl
Tlc:-11000cells
Provessional Diagnosis:-
Acid peptic disease with 8th rib facture..
