case 5

GM Case -5
March 15 june 2023
Case scenario.....
Hi, This is Sara Pranathi,IIIrd BDS. This is an online eblog 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 50 years old women, occupation house wife, Resident of pochampalli
Chief complaints:
Patient came to hospital with severe pain all over the abdominal region since 2days
Vomiting since 2days
Lose stools since 2 days
Fever since 2 days
History of present illness:
Patient was apparently asymptomatic 2days back than had pain all over the abdomen which was incidious in onset since 2days
Patient is having 2episodes of vomiting that is since 2days before coming to hospital .Vomiting characteristics: on first day vomiting contain water, and 2nd day it contains with food particles 
It is non non projectile, non bilious, with food content
8episodes of loose stools, large volume, wateryin nature
Fever low grade
History of pastillness:
Hypothyroidism since 3yrs
No hypertension, diabetes millitus, CVA, CAD, epilepsy, asthma
Personal history:
Diet: mixed
Appatite: normal
Bowl&bladder is regular
Sleep is adequate
No addiction
No allergies
Family history:
No significant family history
General examination:
Patient is consious and cooperative
No signs of pallor, icterus, cynosis, clubbing, lymphadenopathy
Oedema of feet
Built: normal 
Oral : dental caries on 47 tooth
Vitals :
Temperature : 99.5 F
Respiratory rate : 16 CPM 
Pulse rate : 102 BPM
SPO2: 99%
GRBS:130Mg/dl
Systemic examination (abdomin) 
Inspection:     
Oral cavity: dental caries on 47 tooth
Abdomen is obese
Umbilicus in position and inverted
Skin contain scars on, stretch marks are present
No sinuses, dilated veins, hernial arificer
Movement of the abdominal wall are according to respiration
Palpation : 
Tenderness is present all over the absomen
Local rise of temperature
Abdomin soft
No enlarged liver, spleen, kidney
No hepatosplenomegaly
Percussion: 
Tympanic sound is heard
Auscultation:  
Bowl sounds heard

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