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:

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