GENERAL MEDICINE
GM case 6
July , 11, 2023
General Medicine
Case 6
Case scenario......
Hi, I am B.pragathi , 3rd bds student .
This is an online elog book to discuss our patient health data after taking his consent. This is also reflects my patient centered online learning portfolio .
CASE HISTORY
Patient details
A 54 years old male ,occupation farmer, Resident of somavaram presented with
Chief complaints
Discomfort in abdomen and shortness of breath since 3 months.
History of present illness:
Patient was apparently asymptomatic 3 months back , then he noticed abdominal bloating which aggrevated by taking food, and relieved on taking medication.
And also had Shortness of breath since 3 months which is grade 2 (SOB on doing normal daily activities) aggrevated on doing normal daily work and relieved on rest position.
History of past illness:
Trauma to left 8th rib since one day while doing routine labour work and continuous pain in left side of the chest, dragging type pain, aggravates on normal movements and during deep inspiration.
No known case of Diabetes ,Hypertension,Asthma,Epilepsy,Tuberculosis ,CVD,CVA.
Family history
No similar complaints
Personal history
Diet: mixed
Appetite: Normal
Sleep: adequate
Bowel and Bladder movements: regular
Addictions: regular alcoholic since 20years, cigarette smoking everyday 6 since 20years.
Allergies: No
General examination
Patient is conscious, coherent, cooperative
Built : thin
Nourishment: Good
Pallor(palpable conjunctiva): No
Icterus( sclera): No
Cyanosis: No
Clubbing: No
Oedema: No
Lymphadenopathy: No
PROVISIONAL DIAGNOS
Abdominal Distention
Q/ A
1) how long days it takes cure?
2) how to relieve stomach pain and bloating?
Consent form: