70years old male with epigastric pain

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 developed epigastric pain which was insidious in onset and gradually progressive,non-radiating,squeezing type of pain.
Not associated with nausea, vomittings,chest pain, palpitations,SOB.
C/O giddiness,sweating,decreased appetite since 3days
No C/O constipation/ loose stools
C/O fever since 2days - low grade, intermittent associated with chills and rigors, relieved by medication.
C/O burning micturition since 10days which is not associated with abdominal pain
No C/O decreased urine output, pedal edena , facial puffiness

PAST HISTORY:-
No h/o similar complaints in the past
Not a k/c/o DM,HTN,TB, EPILEPSY, CVA,CAD, THYROID DISORDERS, BRONCHIAL ASTHMA.

PERSONAL HISTORY -
mixed diet
Normal appetite 
Regular Bowel and Bladder movements
Sleep -adequate
No allergies 
addictions- Daily toddy consumer since 30years. Tobacco smoking stopped 20yrs back.

GENERAL EXAMINATION 

Patient is conscious coherent and cooperative 
No signs of pallor, icterus, cyanosis, clubbing ,lymphadenopathy and pedal edema
Clinical images 

Vitals-
Temp- Afebrile 
BP-100/60 mm of Hg
PR-102bpm
RR-16cpm
Spo2 -96% on room air
GRBS-152mg/dl

SYSTEMIC EXAMINATION 

CVS-s1,s2 heard,no murmurs 
Rs-BAE +,NVBS
P/A-
SOFT,
TENDERNESS IN EPIGASTRIC REGION
ABDOMINAL GRITH-78 cm
CNS-    
 B/L pupils reacting to light          

TONE-         U/L          L/L
               Rt   N              N
               Lt   N              N
Power             U/L       L/L
                Rt    4/5       4/5
                Lt    4/5        4/5
Reflex            Rt            Lt
                B     2+           2+
                 T      2+           2+
                 S       -             -
                 K       2+          2+
                 A       -              -
                 P       FLEXOR

INVESTIGATIONS



PROVISIONAL DIAGNOSIS:- PYREXIA SECONDARY TO ?AMOEBIC LIVER ABCESS ?PYOGENIC LIVER ABCESS

TREATMENT
1) IVF 10NS@50ML/HR
2)INJ. PAN 50MG IV OD
3)TAB DOLO 650MG PO/BD
4)SYRUP CITRALKA 15ML WITH HALF GLASS OF WATER PO/TID
5)INJ METROGYL 100ML IV TID
6)MONITOR VITALS 6TH HOURLY
7)INJ TRAMADOL 1AMPOULE IN 100ML NS IV

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