GENERAL MEDICINE

GM-CASE 5

Tuesday,March 7th ,2023

March 7th, 2023

CASE scenario....

Hi, I am G Sukanya, 3rd year bds student. This is an online elog 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 presented with the

Chief complaint of

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 .

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. 

Past illness 

No known case of Hypertension /Diabetes/Tuberculosis/Asthma/epilepsy/

CAV

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 Diabetes and hypertension 

General examination 

Patient was Conscious and Co-operative.

Pallor:No Pallor

Icterus:No

Cyanosis:No

Lymphadenopathy:No

Edema-No

Drug history 

ultrasound report

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?