48 M with pain abdomen and lower back pain since 1 week

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.

48 M resident of suryapet, farmer by occupation came to the opd with c/c of lower back pain and pain abdomen since 1 week 


HOPI

patient was apparently asymptomatic 1 week ago and then he developed pain abdomen which was a dragging pain in nature, relieved on medication. no aggravating or relieving factors. he also developed lower back pain since a week which is relieved on medication. the patient also complained of facial swelling since 2 days 


past history 

n/k/c/o dm, tb, epilepsy, htn, 


15 years ago he was admitted in the hospital for 2-3 days due to jaundice and then he was discharged & asked to take medication. 


personal history 


sleep - adequate 

bowel and bladder - regular  

appetite - normal 

addictions - bidi and cigarette smoking since 20 years ago 

alcohol 1 quarter daily since 20 yrs

he stopped since an year because he had pain abdomen and sob 


family history - not significant 


daily routine - 


he wakes up at 4-5 am and then milks the cows 

he then attends to some farm work agriculture work

at around 9 am he eats rice with pickle or curry and then works again in the fields and drives a tractor 

at around 10 pm he eats jawar roti and goes to bed. 

he hasn’t been able to work since five days because of the pain. 


general exam 

patient is conscious coherent and co operative 

moderately built and nourished

pallor- absent 

icterus - mild 

clubbing - absent 

cyanosis - absent 

generalised lymphadenopathy- absent 

pedal edema - absent 








vitals 

Temp: 98.6F 

pulse rate: 65 bpm

Blood pressure - 110/70 mm hg

Respiratory rate: 16 cpm


Systemic examination

 cvs - 

no thrills, 

no cardiac murmurs, 

S1 and S2 sounds heard

 rs -

 dyspnoea is absent, 

position of trachea is central,

 no wheeze, 

vesicular breath sounds present  


abdomen - 

normal in shape, 

no tenderness, 

no palpable mass, 

hernial orifices are normal,

 no bruits or free fluid,

 liver and spleen are not palpable, 

bowel sounds are present. 

cns -

conscious 

speech is normal

kerning's sign is negative 

brudzinskis sign negative

rombergs sign negative

cranial nerves, motor system, sensory system are all intact and normal.


provisional diagnosis - alcoholic liver injury 

investigations -  









treatment - rantac 
                   lasix 




Comments

Post a Comment

Popular posts from this blog

osce

1) Complications of diabetes mellitus Chronic hyperglycaemia causes irreversible damage over time to a number of tissues: particularly the small blood vessels of the retina (retinopathy), the glomerulus (nephropathy) and peripheral nerves (peripheral neuropathy). These are the microvascular complications. They are strongly linked to long term elevated blood glucose.  Macro vascular complications are further divided into coronary circulation ( angina, acute coronary syndrome or myocardial infarction), cerebral circulation (transient ischaemic attack, stroke), peripheral circulation ( foot diseases).  other complications are - infections, rheumatological complications, skin complications.  2. Diabetic neuropathy  symptoms include paraesthesia in the feet, sharp pain in lower limbs ( worse at night and felt mainly on the anterior aspect of the leg), burning sensation in the soles of feet and cutaneous hyperaesthesia. As the condition advances, structural changes appear ...
Read more

60 M WITH TYPE 2 DIABETES MELLITUS AND HYPERTENSION

Image
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. Ihave 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. A 60 year old man, resident of suryapet, labourer by occupation, came to the ophthalmology op with complaints of diminution of vision in the right eye and was referred to the general medicine department because ...
Read more

70M Fever and shortness of breath

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. 70 yrs male resident of velanki , farmer by occupation (not working since two years due to SOB)  Chief complaints :  Fever since 5 days  Dyspnea since 1 day Reduced urine output since 5 days  HOPI :...
Read more