gm case 4

Hi, I am Patel Dinesh, 3rd BDS student.

This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio

        CASE HISTORY 

A 30 year old male patient who is from Suryapet and a farmer by occupation presented to the OPD on 29/11/22 with 

Chief Complaints of 

•Vomitings and abdominal discomfort since 3 days

•SOB since 3 days

HOPI-

The patient was apparently asymptomatic 12 days back(19th November'22) then he developed Yellowish discoloration of eyes which was associated with facial puffiness first and followed by pedal edema which was pitting type.

Then on 23rd he went to a private hospital where he was investigated and was diagnosed to have jaundice.

On 24th he took a herbal medicine(Plants unknown) of 100 ml (half of a disposable glass) . 

On 25th he developed Vomitings which were sudden in onset, 2 to 3 episodes per day initially which eventually progressed to 6 to 7 episodes per day on the day of presentation. Content was bilious vomiting (green in color) with no aggravating and relieving factors. Patient was on complete liquid diet during these 3 days.

Vomitings were associated with diffuse abdominal pain, and fever.

Fever was continuous, with evening rise of temperature and no aggravating and relieving factors.(Not associated with chills and rigor).

Patient also gave history of SOB grade 2 to 3 and Dry non productive cough.

Patient gave a history of Weight loss (>15 kgs) in the last 2 months.

Past History -

Not a K/c/o DM, HTN, TB, Asthma, Epilepsy and CAD.

Personal History -

Appetite - Decreased since 10 days

Diet- Mixed

Bowel and Bladder- Regular

Sleep- Adequate

Addictions- Used to drink alcohol once a week but since 2 months he started consuming alcohol everyday. (Whiskey- 90ml) Last binge 20 days back.

Drug History - Not Significant 

Treatment History - Not Significant 

No known allergies.

General Examination:

Patient is conscious coherent and cooperative, well oriented to time,place and person.

Thin built and moderately nourished

Pallor: Absent

Pedal edema subsided 

No signs of Icterus cyanosis, clubbing , Lymphadenopathy.

Vitals

Temp:

PR: 90 bpm

Bp: 120/70 mmHg 

RR: 20 cpm

Systemic Examination:

CVS:

S1 heard

Loud P2 .

RS:

Trachea central

Normal vesicular breath sounds heard

Abdomen:

No tenderness 

No distension 

Liver and spleen not palpable

Bowel sounds - Normal

CNS- No neurological focal deficit