GM CASE 2
6th March 2023
Case scenario.......
Hi, This is M Sindhuja, 3rd year Bds. This is an online eblog book. Discuss our patient health data after taking his consent. This also reflects my patient centered online learning portfolio.
COMPLINTS AND DURATION
77yrs old male farmer by occupation Resident of narayampuram c/o abdomen pain since 5 days.
History of present illness (HOPI) Patient was apparently asymptomatic until 5 days back.later,c/o abdomen pain with twisted type of pain onset in insidious accompanied with nausea. gradually progressive after taking food.
History of past illness :
Patient c/o Similar complaint 15 yrs back.
Patient h/o emphysema 15 yrs ago, h/o analgesia abuse for knee pains since 3 yrs.
h/o cholecystitis
Moderate ascities.
No k/c/o DM, Hypertension, CAD, Asthma,TB,Blood transfusion.
PERSONAL HISTORY:
Patient has normal appetite and mixed diet, bowl( constipation), micturation(decreased urine output), burning of micturation, no known allergies.
Patient addiction to alcohol and tobbaco (3 beedies per day).
FAMILY HISTORY:
Not significant.
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative.
No pallor,
No cynosis,
No icterus,
No clubbing of finger, toes,
No lymphadenopathy,
No malnutrition,
No oedema.
RESPIRATORY SYSTEM:
Dyspnea
Position of trachea: central
ABDOMEN
Shape of abdomen: distended, tenderness at hypochondrian region,
Bowl sounds heard. The abdomen seems to be swelling due to free fluid accumulated in peritoneal cavity.
VITALS:
Temperature: 97.4
Pulse rate: 80/min
Blood pressure : 110/80mm/Hg
Spo2:98%
PROVISIONAL DIAGNOSIS:
ASCITISES
