Gm case..

Case scenario...

Hi ,I am M.Sindhupriya 3rd bds student.This is an online elog book to discuss our patient 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 complaints:

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. 

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 

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:

Systemic examination:

1.Respiratory system

No dyspnoea

No wheezing

Breathe sounds heard: vesicular normal

2.Cardiovascualr system

Cardiac sounds: S1,S2 heard

3.Abdomen

Shape: distended

No tenderness

No palpable mass

No palpable liver

No palpable spleen

No bruits

Bowel sounds: heard

4. CNS

Conscious

Speech : absent

Coherent higher motor function is intact

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?