case -4

GM Case -4

March 3rd 2023
Case scenario.....
Hi, This is Sara Pranathi,IIIrd BDS. This is an online eblog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.
                           CASE HISTORY
Patient details 
A 21 years old male Resident of choutuppal ,occupation by a  student 
Chief complaint :
Pain near the chest region followed by severe pain near the abdominal region since  2 week.
Multiple episodes[30-40 times] of vomiting and breathlessness Since 2 days .
History of present illness 
Patient was apparently asymptomatic 2 weeks back then had pain near the chest region and  followed by pain near the epigastric and umbilicus region which is insidious in onset and gradually progressive.....pain type dull thrombing .
And patient is having multiple episodes of vomiting, that is 30-40 times  per day since 2 days before coming to hospital....
Vomiting characteristics :
1)Non-projectile type of vomiting, as  the patient felt nausea before he vomit...
2)Contents of vomiting-only water was present, no other food Content. 
3)Color of vomiting -No blood stains /greensih/yellowish and vomiting was colourless/watery liquid. 
4)quantity of vomiting: less amount of vomiting each time ....
5)episodes of vomiting-30-40 times per day.
5)vomiting was aggrievated by eating food or drinking water...
6) pain near the abdominal region while vomiting..
And No relieving factors. 
Shortness of breathe since 2 days which is insidious that is grade 1 and gradually progressed to grade 4. 
History of past illness
No Hypertension 
Diabetes absent
Tuberculosis absent
Asthma absent
Epilepsy absent
No CAV
No 
Drug history:
Personal history 
Diet :mixed
Apetite:loss of apetite 
Sleep:inconvenience in sleeping 
Bowel/bladder -regular 
Habits:Alcoholic since 4 years 
             Consumes Alcohol 4 to 5 days in a week and 2-3 times in a day 
              Alcohol type-whiskey 
              Cigarette smoking since 2 year
               3-4 Cigarettes in a day 
Family history 
No family history complaints
General examination 
Patient was Conscious and Co-operative.
Pallor:No Pallor
Icterus:No
Cyanosis:No
Lymphadenopathy:No
Edema-No

As the patient was chronic Alcohol -
             PROVISIONAL DIAGNOSIS 
                      Liver disease 
                    
Q/A
1)How can I keep my liver healthy?
2)Is there anything I can do myself to stop the disease from getting worse?
3)How will the disease affect me physically? 
4)What type of liver disease do I have?
5)Is the liver disease curable?

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