CASE 6

GM Case 6

Case scenario.....

Hi, this is sai kaushik, 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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