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?



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