Gm case 6

 GM CASE 6 

Case scenario 

March 21

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 40 year old male resident of nedamaluru mandal presented with

Chief complaints:

Patient came to the hospital with chief complaints 

Nausea and vomitings since 3 days - which is non bilious consistency was watery in nature with food particles and no blood stains are seen and relieved with medication after 1 day of on set . Vomitings after bowel works . No pain on passing bowel works. 

Loose motions - 30 episodes per day and after attending hospital frequency reduced to 9 times per day and difficult to flush . It not subsided by taking medication.

Consistency was watery in nature , no blood stains are seen .

Not known case of cough, cold , fever.

History of present illness : 

Cramps in both legs 

Chest pain 

Pain in both legs 

History of past illness: 

similar complaints of loose motions before 10 years 

Not Known a case of hypertension 

N/k/c/o: dm/tb/asthama/ CAD/thyroid disorders/epilepsy.

Family history : no family history 

Personal history:

Diet : mixed 

Occupation : agriculture 

Appetite : normal 

Sleep : normal 

Bowel and bladder : burning micturition 

Not an alcoholic or smoker 

General examination: 

Conscious and cooperative 

Pallor : absent 

Icterus : absent 

Cyanosis: absent 

Edema: absent

Lymphadenopathy: absent

Vitals : normal

Systemic examination:

Inspection: 

Shape of abdomen :obese

No scars are seen 

Flanks are absent 

No swellings around nect or abdomen are seen

Palpation: 

Liver : not palpable

Spleen : not palpable

There is raise in temperature 

Tenderness : present ( pain in umbilical region)

Percussion: 

No free fluid present 

Auscultation: 

Bowel sounds : heard