General medicine Case -7

CASE scenario....

Hi, I am D.Rajashri, 3rd BDS student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolio.

                 CASE HISTORY

Patient Details
A 54 years old male,resident of chityala, daily labour by occupation presented with
Chief complaint
*Abdominal bloating since 2-3 months
*Shortness of breath since 2-3 months
*Pain in the left side of the chest- history of trauma to chest before day
History of present illness
*Patient was apparently asymptomatic 2-3 months ago than he had developed abdominal bloating,which aggravated on food intake, Relieved on medication,not associated with vomitings
*Shortness of breath on exertion(grade 2 MMRC),which aggrevated since 3 months after bloating of abdomen, Relieved on sleeping.
*History of trauma to left 8th rib on before day,while doing routine labour work and continuous pain in left side of chest, dragging type of pain,which aggrevates on movements and Deep inspiration,relieves on taking rest.
*Not a known case of fever,cold,cough, vomitings,loose stools
History of past illness
*Not a known case of Hypertension, Diabetes,CVA,TB,asthama, epilepsy
Personal History
Diet-mixed
Appetite -normal
Bowel and bladder -Regular
Micturition-normal
Allergies -no
Addictions-
*Regular alcoholic since 4-5 years
*4-5 beedies/day since 4-5 years
Family History
No history of similar complaints in the family
General examination
Patient was conscious, coherent and cooperative 
Patient was normally built and normally nourished 
Pallor-absent
Icterus-absent
Cyanosis-absent
Clubbing-absent
Lymphadenopathy-absent
Vitals
BP-130/80mmHg
RR-16 CPM
PR-84 BPM
Systemic examination
A) Respiratory system
*Dyspnea-present
*Tenderness o in the 8th intercostal space
*Wheez-no
*position of trachea-central
*Vesicular Breath sounds are heard

B)Abdomen
Inspection:
*Shape of abdomin-scaphoid
*No scars present
Palpation
*Liver and spleen are not palpable
*Tenderness 

Provisional diagnosis
Fracture in 8th intercoastal space
Intercoastal neuralgia
Gastric problem
Acid peptic disease













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