Gm case 7

 Case scenario.....

Hi, this is P.Minnu, 3 rd BDS student. This is an online e-blog book to discuss our patient's health data after taking his consent. This also reflects my patient centered online learning portfolio.

CASE SHEET:

A 38 year old male came with chief complaint of vomiting since 4 days.

CHIEF COMPLAINT:

 Vomiting since 4 days.

HISTORY OF PRESENT ILLNESS:

Patient was asymptomatic 4 days ago.

He had vomiting since 4 days.

It is non-projectile type of vomiting.

The number of episodes were 6 to 7 times a day.

Frequency decreased to 4 to 5 times a day since one day.

The vomiting was watery contained food particles.

The vomit is not blood tinged.

He has no abdomen pain, fever, headache.

Since 20 days, he had pain in lower limbs ( right and left)

The pain was pricking pain, intermittent.

There was no pain while he was working or walking.

While on rest pain started again.

Since 10 days he quite alcohol and he is on medication.

HISTORY OF PAST ILLNESS:

2 years ago, he is diagnosed with diabetes type 2

4 years ago, he was diagnosed with hypertension. 

he is on regular medication.

He has no history of asthma, tuberculosis, thyroid disorders.

FAMILY HISTORY:

No significant complaint.

PERSONAL HISTORY:

Occupation: agriculture

Diet: mixed

Appetite: normal

Sleep : normal

Bowl and bladder: normal

Addiction: alcohol regularly( 1 liter per day)

                       smoking (cigarette) he stopped 5 years ago.

Allergy: no

GENERAL EXAMINATION

Pallor: no

Cyanosis: no

Icterus: no

Clubbing: no

Lymphadenopathy: no

Oedema: no

4 years ago, he was diagnosed with hypertension. 

he is on regular medication.

He has no history of asthma, tuberculosis, thyroid disorders.

FAMILY HISTORY:

No significant complaint.

PERSONAL HISTORY:

Occupation: agriculture

Diet: mixed

Appetite: normal

Sleep : normal

Bowl and bladder: normal

Addiction: alcohol regularly( 1 liter per day)

                       smoking (cigarette) he stopped 5 years ago.

Allergy: no

GENERAL EXAMINATION

Pallor: no

Cyanosis: no

Icterus: no

Clubbing: no

Lymphadenopathy: no

Oedema: no

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