General Medicine Case-5

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 21 years old male , resident of choutuppal, presented with

Chief Complaint

*Severe vomitings since 2 weeks

*Stomach pain since 2 weeks

*Shortness of breath 1 week

History of present illness

*Patient was assymptomatic 2 weeks back,later there was onset of, more than 10 episodes of vomiting in 24 hours with nausea .

Vomiting on drinking of water, with white foam, without fowl smell.

*Patient complained with pain in epigastric region , which was due to heaviness,non radiating pain.Went to near by government hospital but not relieved on medication. pain is aggregating on sitting and relieving on sleeping.

*Patient complained with shortness of breath since one week,which is being aggregating on talking and relieving on rest

History of past illness

Not a known case of hypertension, diabetics, asthama

Patient took poison 8 months back and gastric lavage has been done

Family history

No history of similar complaints in the family

Personal history

Patient is alcoholic since 4 years

Patient has the habit of smoking

Diet-mixed diet

Loss of appetite

Sleep-inadequate

Bowel and abnormal -abnormal 

General Examination

Patient is concious, cooperative

Normally built and normally nourished

Pallor-absent

Icterus -absent

Cynosis -absent

Edema-absent

Lymphadenopathy-absent

Clubbing -absent

Vitals

Blood pressure -130/70 mm Hg

Pulse Rate-120 bpm

Respiratory Rate-36 cpm

Provisional Diagnosis

Alcoholic ketoacidosis 

Q/A

*Do excess drinking is the main cause for vomiting

*What is the cause for increased pulse rate and respiratory rate?