General medicine case history 5

Hii this is E.Bhargavi,3rdBDS student.This is an online eblog book to discuss our patients health data after taking his consent . This is reflects my patient centered online learning portfolios

Chief Complaint :-

A 54 years old man come to OPD with cheif complaint of abdomin pain and discomfort since 2 months

History of present illness:-

Paitent was aparently asymptomatic before 2 months back.. Now he developed Abdominal bloating since 2 months.. 

Which is aggrevating on food intake

Relieving on medication.. 

Belching present

No regurgitation.. 

Shortness of breath which is of grade 3..since 2 months

Aggrevating on working And after bloating of abdomen

Relieving on sleep..

Negative history:-

No chest pain, palpations, orthopenia, decrease in urine out put.. 

History of Trauma to left 8th rib while he doing routine labour work and continuous pain in left chest side which is of dragging type of pain.. 

Aggrevating on movents and deep inspiration.. 

No history of fever, vomiting, loose stools

History of past illness:-

Diabetes:- no

Hypertension:- no

Asthma:- no

Tb:-no

Epilepsy:- no

Personal history:-

Diet:- mixed

Appetite:-normal

Sleep:- regular

Bowl and Bladder:- normal

Addiction:- daily 90ml in the evening

Smoking of bidi 10 bidis per day

Family history:-

No such relavent history.. 

General examinations:-

Patients is co operative and conscious

Bulit:- modrate

Nourishment:- well

Pallor:- no

Icterus:- no

Clubbing:- no

Cynosis:-no

Lympadenopathy:- no

Edema:no. 

Systemic examination:-

Respiratory system:-

Inspection:-

Upper respiratory tract:- oral hygiene not good 

caries present 

stains present

No haltolis

No nasal septum deviation

No sinus tenderness

No tonsils

Lower respiratory tract:-

Chest is symmetrical

No drooping of shouler

Trachea midline

No suprascapylar and intrescapular hallowong

No pectus carnitum, no pecrus escavum and kphyscolisis

Palpation:-

Inspectory finding are conformed in palpation

Superficial

Rise in temperature

Trachea midline

No drooping of shoulder

Transverse 50

Anteriposterior30 

Thoracic circumference 80

Semi thoracic 40

Percussion:-

Clavicular supra and inta 

Mammilary

Auxiliary infra and supra

Suprascapular and infrascapular

All resonate sounds heared

Auscultation

Vesicular breath sounds 16 / min.

Vitals:-

Bp:- 120/80

Temperature;- 97.4

Pulse:- 75 per min

Investigation:-

Hemogram

Hb:-13.4

RBS:-97mg/dl

Tlc:-11000cells

Provessional Diagnosis:-

Acid peptic disease with 8th rib facture..