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.

Comments

Post a Comment

Popular posts from this blog

A 48 year old female came with the complaints of swelling in face hands and legs.

Image
                       E LOG GENERAL MEDICINE. Hi, I am Anvitha, 3rd Sem Medical Student.  This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio. This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.  * This is an ongoing case. I am in the process of updating  and editing this ELOG as and when required                                    CASE SHEET.                                             Chief complaints and duration. A 48 year old female patient who is a housewife by occupation came to the opd with the chief complains of bilateral pedal edema and puffiness of the face. History of present illness. Patient was apparently asymptomatic one year back when she developed bilateral pedal edema (pitt
Read more

A 40 year old female patient came with the chief complains of dry cough since one week and left upper and lower limb weakness since two years.

Image
            E LOG GENERAL MEDICINE. Hi, I am Anvitha, 3rd Sem Medical Student.  This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio. This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.  * This is an ongoing case. I am in the process of updating  and editing this ELOG as and when required                                    CASE SHEET.                                             Chief complaints and duration. A 40 year old female patient came with the chief complaint of dry cough since one week and weakness of upper and left lower limb since two years. History of present illness. Patient was apparently asymptomatic two years ago then she developed fever and next day while going to farm she deve
Read more

A 74 year old male patient came to the opd with the chief complains of giddiness.

Image
                  E LOG GENERAL MEDICINE. Hi, I am Anvitha, 6th Sem Medical Student.  This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio. This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.  * This is an ongoing case. I am in the process of updating and editing this ELOG as and when required .                                    CASE SHEET.                                            Chief complaints and duration. A 74 year old male patient came to opd with the chief complain of giddiness and weakness for five hours on Thursday afternoon. History of present illness. Patient was apparently Asymptomatic till Thursday afternoon then he developed headache which relieved on medication then that eve
Read more