Final short case
Final short case
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
A 35 year old male patient presented to the opd with chief complaints of pain in the upper abdomen since one week and fever since one week
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic one week back and then developed pain in the upper epigastric region and right upper hypochondria region which is insidious in onset and progressively growing in nature
There is a bit relief of pain on standing position and a little aggravation on sleeping
Fever which is present is one and off and there are no presence of chills , rigors, cough ,nausea , vomitings
There are no bleeding manifestations seen
PAST HISTORY:
patient is not a known case of asthma , hypertension , epilepsy, diabetes
PERSONAL HISTORY:
Diet - mixed
Appetite - decreased since one week
Sleep - adequate
Bowel movements - black stools
Bladder - burning micturition
Addictions - regular alcoholic since 10 years
Smoking since 10 years
GENERAL EXAMINATION:
Patient is conscious, coherent , cooperative and well oriented to time and place
No signs of clubbing , cyanosis
Icterus - seen
Pedal edema - seen
VITALS :
Temp : afebrile
BP: 110 / 70
Pulse rate : 86 bpm
Respiratory rate : 20 cpm
Spo2 - 98% on RA
SYSTEMIC EXAMINATION :
RS - bae + , nvbs
CVS - S1,S2 +
P/A - tenderness + at eight hypochondrium and epigastric region
INVESTIGATIONS :
Comments
Post a Comment