GENERAL MEDICINE

GM- CASE 1

Tuesday, 28 February 2023

28 February 2023
CASE scenario....

Hi, I am k.saimadhuri, 3rd year 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 : A 60 year old Male known case of stomach pain with vomiting 
CHIEF COMPLAINTS : stomach pain  and vomiting since 3 days.

HISTORY OF PRESENT ILLNESS : 
Patient was apparently asymptomatic 1 years back since last 3 days the pain is severe with vomiting . Stomach Pain is at left hypochondrium and radiates to other parts around umbilicus. The pain is dull and dragging pain. He consulted local doctor they diagnosed it as peptic ulcer and used medication for it. Vomiting from 3 days 2 episodes per day with food particles and it is projectile .
 AGGREGATING FACTOR: sore taste

PAST ILLNESS :
Diabetes:no
Hypertension:no

PERSONAL HISTORY : 
Mixed diet, Normal appetit, have proper sleep, regular bowel,  micturition is normal, no habits.

FAMILY HISTORY : 
Not significant 
GENERAL EXAMNLINATION : 
Built : thin
Nourishment : poor 
Consciousness: in Conscious
Pallor : no  
Icterus : no
Cyanosis : no  
Clubbing : no 
Lymphadinopathy : no 
Edema : no 

VITALS : 
Temperature : 97.5°c/f
Pulse : 88_ beats per minute
Respiratory rate : 20_cycles per minute
Blood pressure : 160/100 mm of Hg
SPO2 : 98%

PROVISIONAL DIAGNOSIS : 
          Acute pancreatitis 


Q/A

1.Is this a curable disease 


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