case 7

GM Case 7

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 67 year old male came with chief complaint of shortness of breath since 1 week. Fever since 5 days. Vomiting since 2 days. Loose stools since 2 days.

CHIEF COMPLAINT:

Shortness of breath since 1 week.

 Fever since 5 days.

 Vomiting since 2 days. 

Loose stools since 2 days.

HISTORY OF PRESENT ILLNESS:

Patient is apparently asymptomatic 1 week ago.

When he noticed shortness of breath since 1 week.

The shortness of breath is insidious on onset and gradually progressive from grade 2 to grade 3.

There is no chest pain

The pain in abdomen since 1 week.

The pain is on and off on left lumbar region.

Fever since 3 days which is high grade at evening there is local rise in temperature.

Fever is associated with chills, rigors which is relieved on medication.

Vomiting since 2 days.

Vomiting is watery, non-projectile, non- bilious, 2-3 episodes per day.

Vomiting consists of food particles, no blood ting.

Loose stools since 2 days which is watery, non- mucoid ( no blood &foul smell) 2-3 episodes per day.

HISTORY OF PAST ILLNESS:

Hypertension since 10 years he is on medication.

Renal stunting since 6 months ago.

FAMILY HISTORY:

No similar compliment.

PERSONAL HISTORY:

Diet - mixed

Bowel and bladder- irregular, decrease urine output.

Sleep- adequate

Appetite- lost since 1 week

Addiction- Alcohol (stopped 1 year ago)

                    tobacco chewing(stopped 1 week ago)

GENERAL EXAMINATION:

Pallor: no

Icterus: no

Cyanosis: no

Clubbing: no

Lymphadenopathy: n0

Edema : no

Built: well built

Nourishment: well nourished

SYSTEMIC EXAMINATION

                                                  RESPIRATORY EXAMINATION

INSPECTION

UPPPER RESPIRATORY TRACK: normal

NASAT SEPTUM: in midline

ORAL CAVITY: poor oral hygiene, caries are present, no gum hypertrophy, no pharyngeal deposits 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 : 38cm

                            anterio posterior: 25cm

                               AP: T = 1.5

PERCUSSION:

Resonant sounds are heard.

                                                            GIT

INSPECTION

UPPPER RESPIRATORY TRACK: normal

NASAT SEPTUM: in midline

ORAL CAVITY: poor oral hygiene, caries are present, no gum hypertrophy, no pharyngeal deposits are seen

OROPHARYNX: normal

UMBILICUS POSITION: Central inverted

SHAPE : obese, equal on both sides. 

FLANGS AND DISTENSION: free

DILATED VEINS: no

SCARS: present (renal stunting)

SINUSES: no

VISIBLE PULSATION: no

All quadrants are moving equally on inspiration

PALPATION:

There is local rise in temperature.

Superficially, no palpable mass, tenderness is seen.

Deep, no palpable liver or spleen.

PERCUSSION:

No fluid thrills, shift in dullness

no puddle's sign.

liver- 14.5cm

AUSCULTATION:


Bowel sounds are heard in left iliac region.

PROVISIONAL DIAGNOSIS:

Left uretic obstruction.




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