GM case -3

​Case scenario…


Hi, I am D. Samhitha , 3rd BDS student . This is an online elog book to discuss our patient’s health data after taking her consent . This also reflects my patient centered online learning portfolio . 


                CASE HISTORY 

PATIENT DETAILS : 

A 55 year old female , named lingamma , resident of mungolu village , a housewife presented with - 

CHIEF COMPLAINTS: 

The patient has complained of sever pain in the left side of stomach since 4 days . 

HISTORY OF PRESENT ILLNESS: 

The patient was apparently asymptomatic before 4 days . 

She has pain in the left abdominal region since 4 days and also intermittent fever since 3 days . 

Pain : Onset - insidious 

          Duration - since 4 days 

          Characteristic - Burning type of pain 

          Localisation - Non radiating pain 

          Frequency- intermittent 

          Aggregating and relieving factors - No relevant  aggregating and relieving factors seen .

PAST HISTORY: 

Not a known case of diabetes, hypertension, TB , Epilepsy, Asthma 

FAMILY HISTORY: 

No relevant family history .

PERSONAL HISTORY : 

Diet - Mixed

Appetite- Normal

Bowel movements- Regular

Micturition - Normal

Sleep - Adequate 

GENERAL EXAMINATION : 

The patient was conscious but not cooperative while taking Case history .

Built - Thin 

Nourishment- Poor

Pallor -No

Cyanosis - No

Clubbing - No

Lymphadenopathy- No

Edema - Present ..( Pitting type , till knee , since one day)







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