GM case 4

April 3,2023

GM case 4

Case scenario....

Hi, this is  M Sharath chand , 3 rd BDS student. This is an online eblog book to discuss our patient's health data after taking his consent. This also reflects my patient centered online learning portfolio.

CASE SHEET:-

A 7 year old female with sever vomiting and loose stools

Chief Complaint:

loose stools for 3days

vomiting for 3 days

Abdominal pain for 3 days 

HISTORY OF PRESENT ILLNESS:

3 Days earlier patient was asymptomatic. Later she developed loose stools and vomiting 3 episodes in a day.

The stools was watery. 

The vomiting contained food particles.

Abdominal pain in lumbar region on and off for 3 days.

PAST HISTORY:-

No similar complaints in the past.

PERSONAL HISTORY:

Occupation: student(2nd grade)

Appetite: lost

Diet: non- vegetarian

Bowel: regular

GENERAL EXAMINTION:-

Pallor : Yes

Icterus: no

Cyanosis: no

Clubbing: no

Lymphadenopathy: no

Edema: no







VITALS:-

Temperature: 96F

Pulse: 72 beats per minute

Respiratory rate: 24 cycles per minute

Blood pressure:80/60 mm/Hg

SPO2: 98%

SYSTEMIC EXAMINATION:-

Cardio Vascular System:

Cardiac sounds: S1, S2 heard

Cardiac Murmur: no

Abdomen: soft

Tenderness: no

No organomegaly

Nervous system: child was nervous



PROVISIONAL DIAGNOSIS:

Dehydration

Questions from patient:-

How much water do I have to consume each day?

How do you treat dehydration?

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