GM CASE

August 28, 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 :

A 55 year old man who is resident of choutuppal

Chief complaint:

Headache since 2years

Chest tightness  since 10years

History of present illness: 

Patient was apparently asymptomatic until 10years then had left side chest tightness, prickling type of pain , insidious onset, non radiating,  aggrevating on having dal , relieved after taking PPI , no belching , nausea, abdominal pain

Since 2years patient had headache , unilateral left sided throbbing pain, insidious onset , radiating from temporal lobe to occipital , associated with left eye blurring of vision, lacrimation of eye

No photophobia , phonophobia

One year ago patient had one episodic of loss of consciousness lasting for 5mins

No involuntary movement since 10days patient had flank pain insidious onset radiating to loin, sharp pain aggrevatedon walking continous pain with burning micturition.

 HIstory of past illness:

N/H/O - hypertension,  DM, asthma, thyroid, CAD , TB 

Personal history: 

Appetite-normal

Diet- veg

Bowel- regular

Micturition- burning micturition 

Allergies- no

Habits- no

Family history: not significant 

General examination:

Pallor - no

Icterus- no

Cyanosis- no

Clubbing - no

Lymphadenopathy- no

Oedema- no

Systematic examination:

 Cardiac : 

Thrills- no

Cardiac sounds- s1 s2

Cardiac murmurs - no

Respiratory:

Dyspnoea - no

Wheeze- no

Position of trachae- central

Breathe sounds- vesicular 

Abdomen:

Shape- scaphoid

Tenderness- no

Palpable mass- no

Hernial orifice- normal

Free fluid- no

Bruits- no

Liver- not palpable 

Spleen - not palpable 

Bowel sounds- present 

CNS :

Conscious

Speech is normal 

Provisional diagnosis

Migraine 

Gastritis