GM case 1

February 20,2023
 
GM case 1
Case scenario...
Hi, this is P.Bhavana,3rd BDS student.This is an online eblog book discuss our patients health data after taking his consent.This also reflects my patient centred online learning portfolio.
CASE SHEET: A 40years old male with yellow discoloration of eyes and Itching all over the body.
 
CHIEF COMPLAINT: 
Yellow discoloration of eyes since 20 days,
Itching all over the body since 20 days.Patient was apparently asymptomatic 20 days back.
Then he developed discoloration of eyes and greenish yellow discoloration of urine. Loss of appetite ,relieved on medication which was prescribed by local RMP.Loss of weight in these 20 days.

HISTORY OF PRESENT ILLNESS:
AAbdominal tightness -Present intially now relieved after medication.
Incomplete evacuation of stools since 20 days,passing pale coloured stools.
Fever: Nil
Vomiting: Nil.
ASSOCIATED DISEASES : Type ll diabetes mellitus.

HISTORY OF PAST ILLNESS: K/C/O DM II since u months .
Hypertension: Nil
Asthma :Nil
TB:Nil
 
PERSONAL HISTORY:
Occupation: Daily wage labourer.
Appetite:lost ,relieved after medication.
Diet:Non vegetarian.
Bowels:Regular.
Micturation:Normal.
Allergies:Nil.

Addictions: Alcohol consumption regularly from 20 years.
No smoking habits.

 FAMILY HISTORY: Not significant.
GENERAL EXAMINATION:
pallor:no
Icterus:no
Cyanosis:no
Clubbing:no
Lymphadenopathy:no
Edema:no

VITALS:
Temperature:98.6°c/f
Pulse:80 beats per minute
Respiratory rate : 16cycles per minute
Blood pressure:100/60mm/Hg
Spo2:98%

SYSTEMIC EXAMINATION:
Cardiac vascular system:
Thrills:no
Cardiac sounds:S1,S2 heard
Cardiac murmurs: No

RESPIRATORY SYSTEM:
Dyspnoea: No
Wheeze:No
Position of trachea: central
Breath sounds : vesicular

ABDOMEN:
Tenderness: no
Palpable mass:no
Liver: palpable.

PROVISIONAL DIAGNOSIS:
JAUNDICE.

Questions from patient 
What is the treatment for jaundice?
How long will it take to cure jaundice ?


 


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