GM CASE

August 21,2023

Case scenario 
Im Sanjana MP, 3rd year bds student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patients centered online learning portfolio 

Case history 
An 65 years old man resident of uthatoor who is a farmer 

Chief complaint :
Constipation and difficulty to pass urine since 2days 
Difficulty in breathing since 2days 

History of present illness : patient was apparently asymptomatic 2days ago then suddenly patient had complaint of shortness of breath since 2days which was present with farm work started insidiously, subsides by taking rest , unable to pass urine and stools which is insidious in onset. No aggravating or relieving factors , no history of fever , no similar complaints in past

History of past illness: no history kf hypertension/ DM / asthma/ CAD/ thyroid/ 
No past surgical history 

Personal history : Appetite- normal 
Diet- mixed 
Bowel- irregular constipation 
Micturition- irregular 
Allergies - no
Habits alcohol - occasionally 

Family history: not significant 

General examination:
Pallor - no 
Icterus- no 
Cyanosis- no
Clubbing- no
Edema- no
Lymphadenopathy- no

Systemic examination :
Abdominal examination :
Inspection: 
Shape- scaphoid with no distention
Umbilicus- inverted
Equal symmetrical movements in all the quadrants with respiration 
No visible pulsations , peristalsis, dilated viens and localised swelling 
Palpation:
Superficial-there is no tenderness ,no local rise of temperature 
Deep- no Palpable mass
Liver - not palpable
No splenomegaly 
Percussion:
Fluid thrill- absent
Traubes space- resonant
Auscultation: 
Bowel sounds - present 
No bruits or venous hum

Provisional diagnosis: gastritis

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