SOB Grade [IV] and Abdominal distension (31 year old man) GM CASE - 6
25th August 2022
CASE STUDY 6
Hello, I am Saloni .S. Gangotri , a 3rd semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.
CASE SHEET:
CHIEF COMPLAINTS:
c/o
- Shortness of breath of Grade IV since 15 days
- Abdominal distension since 20 days
HISTORY OF PRESENT ILLNESS:
Patient was discharged 15 days back with medication. He was on medication for the 5 days and stopped 2 days back.
He has decreased appetite and good intake since 2 days.
Distension increased on eating and decreased on motion.
He has taken alcohol and had eaten chocolates.
Dry cough since 5 days and took medication for the same.
Fever 2 days ago, relieved on medication.
ASSOCIATED DISEASES:
———
PAST HISTORY:
h/o
No K/C/O DM, HTN, Epilepsy, TB, CAD.
PERSONAL HISTORY:
Regular Bowel movements.
Has normal micturition with no burning sensation.
Has no known allergies.
Decreased appetite.
FAMILY HISTORY:
Has no history of Diabetes Mellitus, No HTN, No Cardiac Strokes, No cancers.
DRUG HISTORY:
GENERAL EXAMINATION:
-No palor
-No cyanosis
-No lymphadenopathy
-Icterus present
-No edema of feet
-No clubbing of fingers
-Temp - normal
-GRBS - 157
VITALS:
Temperature: febrile
Pulse: 116 beats per minute
Respiratory rate: — cycles per minute
Blood pressure: 110/60 mm of Hg
SPO²: 90
SYSTEMIC EXAMINATION:
Cardiovascular system:
No thrills
No murumurs
Cardiac sounds: S1, S2 present
Respiratory system:
No dyspnea
No wheezing
Breath sounds heard: vesicular? yes
Abdomen:
Shape : Scaphoid
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard
Central Nervous System:
Conscious and Alert
Speech: Normal
INVESTIGATIONS:
Biochemical investigations:
ECG:
2D-ECHO REPORT:
ULTRASOUND REPORT:
GRAPHIC SHEET :
PROVISIONAL DIAGNOSIS:
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