A 48 YEAR OLD MALE CAME WITH PAIN ABDOMEN AND LOW BACK PAIN.

 Hi, I am Anvitha, 3rd sem medical student.This is an online elog book to discuss our patients health data after taking her consent.This also reflects my patient centered online learning portfolio.


CASE SHEET:

Chief complaints:

A 48 year old male, industrial worker by occupation came to OPD with chief complaints of:
-pain abdomen since 5 years
-constipation since 5 years
-pain in neck region since 1 year
-low back pain since 1 year
-shortness of breath since 1 year

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 5 years back. He then developed pain abdomen which was left side and umbilical region each episode lasted for 4 to 5 hours.

 He also had complaint of constipation since 5 years.No history of blood in stools.

He also complained about neck pain on back side since 1 year which aggravated on movement of head.

Associated diseases:
Not significant

Past history:
 Not significant

PERSONAL HISTORY: 

Diet: Mixed
Bowel habits: Constipation since 5 years
Micturition: Normal
Appetite: Decreased
Addictions: Chronic smoker since 20 years
No history of asthma, allergies, tuberculosis, coronary artery disease

Family history:

Not significant

Drug history: 
Pan 40
Clavum 625 
Montek-LC (10/5)

GENERAL EXAMINATION: 

No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No pedal edema
No dehydration


Vitals:

Temperature: afebrile
Pulse: 78 beats per minute
Blood pressure:110/80 mm of Hg
SPO2:96%

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills
Cardiac sounds: S1, S2 heard
Cardiac murmurs: no

Respiratory system:

No Dyspnea
No wheezing
Position of trachea: Central
Breath sounds heard: vesicular

Abdomen:
 
Shape: 

Tenderness: right iliac fossa and umbilical region
No palpable mass
Non palpable liver
Non palpable spleen
Bruits: absent
Bowel sounds: absent

Central nervous system: 

Conscious
Speech: normal

INVESTIGATIONS:
USG:

ECG:

Provisional Diagnosis :
Pain abdomen under evaluation, cervical spondylosisspondylosis.

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