GM case -3
CASE scenario....
Hi, I am D.Rajashri, 3rd 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 38 years old male,resident of lingotam village ,works as a daily labour presented with
Cheif complaint
Vomitings since 3 days
History of present illness
The patient was apparently alright 9 years ago later he took poison due to some personal issues and gastric lavage has done .
After that he used to have 3-4 episodes of vomiting for 2-3 days once or twice in the year,and was relieved on medication
Vomiting consist of food particles and was yellowish colour, occurs even before and after taking food and is associated with squeezing of stomach
History of past illness
Not a known case of hypertension, diabetics,CAD,asthama,TB
Family history
No history of similar complaints in the family
Personal history
Diet-mixed diet
Appetite -normal
Sleep-adequate
Bowel and blady-normal
Alcoholic person
General Examination
Patient was conscious and cooperative
Patient was normally built and normally nourished
Pallor-absent
Icterus -absent
Cynosis -absent
Clubbing -present
Edema -absent
Vitals
Temperature -98° F
Blood pressure -120/80 mm Hg
Pulse Rate-76 bpm
Respiratory Rate-16cpm
SPO2-98% on RA
Q/A
*Is alcohol consumption main reason for the vomiting?
*Is there any infection caused to kidney?
*What will happen if the patient vomits for more than 4 times a day?