40y/M with c/o pain abdomen

40y/M with c/o pain abdomen

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT     

CHEIF COMPLAINTS:
c/o pain Abdomen since 4 days 
HOPI:
Patient was apparently asymptomatic 4days back then developed pain over the left hypochondriac region since 4 days radiating to the right hypochondriac region 
C/o vomiting since 4days ,3 episodes watery in consistency ,non-blood stained,non foul smelling
No c/o fever , decreased urine output ,loose stools
H/o Burning micturition since 4days 
C/o SOB , palpitations, orthopnea,pnd 
PAST HISTORY:
Not a known case of HTN,DM,Asthma,Epilepsy.

PERSONAL HISTORY: 

Diet - Mixed
Appatite - Normal
Sleep - Normal
Bowel and Bladder -Regular.
Allergy - None
Addictions -Alcohol addiction since 10 years last consumption was 2 days back.

FAMILY HISTORY: 

No history of similar complaints in the family.

GENERAL EXAMINATION:

The patient is conscious,coherent and cooperative; well oriented to time,place and person.
Pallor - absent

Icterus- absent

Clubbing-absent

Cyanosis-absent

Lymphadenopathy-absent

Edema - absent 

VITALS:

Temperature - 98.6 F.

Blood pressure - 140/90 mmHg

Pulse rate - 85/ minute 

Respiratory rate - 18/minute

SYSTEMIC EXAMINATION:

CVS: 
S1 and S2 heard. 
No addded thrills or murmurs heard

RESPIRATORY SYSTEM:  
Normal vesicular breath sounds heard. 
Bilateral air entry present.

ABDOMEN:

INSPECTION:
shape of abdomen - distended
umbilicus -central
no sinuses
No scars
PALPATION:
Tenderness+ over hypochondriac region
Fluid thrill +
Puddle sign +
PERCUSSION:
No shifting dullness
AUSCULTATION:
Bowel sounds +

CNS:
Conscious and coherent.
Normal sensory and motor responses.

INVESTIGATIONS:



USG
ECG
CHEST X RAY

PROVISIONAL DIAGNOSIS
?Acute Pancreatitis

Popular posts from this blog

A 41 year old female with diabetes, abdominal pain ,nausea and vomiting

Image
A 41 year old female with diabetes, abdominal pain ,nausea and vomiting July 29, 2023 July 29,2023 Hi,I am poojitha, Sri 5th semester student.This is an online elog book to discuss our patient health data after taking his consent.this also reflect my patient centered online learning portfolio.                         CASE SHEET CHIEF COMPLAINTS:  A 41 year old female housewife  from Miriyalguda came to casualty with C/O: Nausea and vomiting since 3days Abdominal pain since 3days HISTORY OF PRESENT ILLNESS : Patient was apparently asymptomatic 4days back then she developed nausea and vomiting, 8-10 episodes of vomiting, content food material watery, non bilious, non projectile, not blood binged and associated with Abdominal pain of diffuse type and non radiating. No H/O chest pain, Pedal edema, burning micturition, coughing, palpitations, excessive sweating, giddiness and wheeze H/o skipping OHAs since 2 days HISTORY OF PAST ILLNESS: K/c/o Diabetes Mellitus type 2 since 2 years for whic
Read more

70years old male with epigastric pain

Image
70years old male with epigastric pain  July, 27,2023 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan Patient came to the casualty with c/o epigastric pain since today morning (21/7/23) HOPI:- Patient was apparently normal until today morning. He then develope
Read more

A 52 year old patient came to casualty with c/o shivering in right leg since 10 am with associated numbness

Image
 52 year old patient came to casualty with c/o shivering in right leg since 10 am with associated numbness July 04 2023  July 4th 2023. This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. Chief complaints:  52 year old Patient came to casuality with complaints o
Read more