GM CASE 5
Case scenario
March 15
Hi, I am karnati Tejaswi 3rd BDS student.
This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio
CASE HISTORY
Patient details:
A 35 year old male resident of choutuppal presented with
Chief complaints:
Patient came to the hospital with chief complaints of pain in the abdominal region from past 5 days which is insidious in onset and gradually progressive and relieved with medication and subsided now.
Fever from past 3 days which is intermittent type not associated with chills and rigor.
Nausea and vomitings - 10 episodes per day which is non bilious consistency was watery in nature with food particles and no blood stains are seen .
History of present illness :
Shortness of breath at rest which is insidious in onset and gradually progressive.
Edema in both legs .
Chest pain and burning micturition.
History of past illness:
No similar complaints in the past
Known case of hypertension from past 3 years
N/k/c/o: dm/tb/asthama/ CAD/thyroid disorders/epilepsy.
Family history : no family history
Personal history:
Diet : mixed
Appetite : normal
Sleep : normal
Bowel and bladder : burning micturition
Alcoholic patient since 7 years
Consumption of tobacco since 6 years
General examination:
Conscious and cooperative
Pallor : absent
Icterus : absent
Cyanosis: absent
Edema: present in both legs
Lymphadenopathy: absent
Vitals : 140/100 bpm
Systemic examination:
Inspection:
Shape of abdomen :obese
No scars are seen
Flanks are present
No swellings around nect or abdomen are seen
Palpation:
Liver : not palpable
Spleen : not palpable
There is raise in temperature
Tenderness : present ( pain in epigastric region)
Percussion:
No free fluid present
Auscultation:
Bowel sounds : heard
Provision diagnosis:
Acute pancreatitis.
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