A 50 yrs old male patient with abdominal pain (Long Case)
50 year old male patient with abdominal pain.
ECG on 16 -01
on 17 -01
Bp -
This is an online E logbook to discuss our patients' de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome.
Date of admission: 16-01-2023.
Cheif complaint: A 50 year old male, farmer by occupation came to the opd with the chief complaints of abdominal pain since 1 month
History of present illness:-
Patient was apparently asymptomatic 1 month back, then he developed abdominal pain in epigastric region and Right hypochondric region ,after consumption of food associated with bloating sensation since 1 yr and also associated chest pain ( retrosternal).
Squeezing type of pain, non radiating, increases after food consumption and after lifting heavy weights relieving on its own
Pain lasts for 30 minutes during the episode
No h/o weight loss
No h/o vomitings
No h/o diarrhoea or constipation
No h/o loss of appetite
No h/o fever
No h/o blood in stools
No h/o burning micturition
No h/o shortness of breath
No h/o regurgitation of food.
Daily Routine :-
Patient wakes up at 6 am brushes his teeth and takes bath by 7 am. Thn he has his breakfast ( rice or upma) , thn he goes to field for work by 8 am . He works there thn returns back by 1 pm, takes bath , thn has lunck ( 2 rotis and a bowel of rice with curry). Thn he stays in home only takes rest. He has his dinner by 8 pm (2 rotis n rice n daal ). He goes to sleep by 9 pm.
Past history -
Patient had an accident 16 yrs back due to overriding of bike due to which he had fracture of teeth.
No similar complaints in the past.
k/c/o Hypertension since 1 yr (telmisartan 40 mg OD, amlodipine 4 mg)
H/o scabies 1 yr ago ( resolved now)
N/k/o DM, Asthma, Epilepsy, CAD, TB.
Personal history:
-Diet - Mixed
-Appetite - normal
-Bowel and bladder movements- Regular
-Sleep- adequate.
-Addictions - Patient consumes alcohol occasionally ( twice weekly 150 ml) smokes cigarette (8-10 or a box full per day) , chews khaini and betel leaf(pan) 3-4 times daily.
Family history:
-No significant family history.
General examination:
-Patient was examined after taking his consent.
-Patient was conscious, coherent, cooperative, well oriented to time place and person, well nourished and well built
.
Oral Cavity :- showing stains 
-Icterus- absent
-Clubbing- absent
-Cyanosis- absent
-Lymphadenopathy - absent
-Edema- absent.
Vitals:
-Temperature: afibrile
-Blood pressure:130/80mmhg
-Pulse rate:88 bpm.
-Respiratory rate:16 cpm.
Systemic examination
-Abdomen:
Inspection:-
-Shape of the abdomen- Scaphoid
-Flanks: flanks are free
-Umbilicus- centrally placed and inverted.
-Sinuses and scars- no visible sinuses and scars are seen.
-Dilated Veins- no visible veins
-No visible peristalsis or no visible pulsations
-All quadrants moving equally on respiration
-Bruits: No
Palpation:
-Done in supine position with hands by side of the body.
-Mild tenderness in right hypochondriac region.
- No local rise in temperature.
-No rigidity is felt.
-No palpable mass
Hernial orifice:normal
-No organomegaly.
-liver: not palpable
-spleen: not palpable
Percussion:
-Tympanic note is heard.
Auscultation:
- Bowel sounds are heard.
Respiratory examination:
-Chest is bilaterally symmetrical.
-Movements with respiration are equal on both the sides.
-Trachea appears to be in center.
-No kyphoscoliosis.
-Normal Vesicular breath sounds are heard.
Cardiovascular examination:
- Elliptical & bilaterally symmetrical chest
- Apex beat palpable at 5th intercostal space medial to midclavicular line
- S1 , S2 heard
- No murmurs.
-no trills
CNS examination:
-No focal neurological deficets .
-Speech is normal.
-Memory is intact.
-cranial nerves:normal
-Motor and sensory system:normal
Provisional Diagnosis :-
Liver abscess
Investigations -
Fever Chart -
X ray :-
Ultrasound- on 11 -12 - 2022
16-01
2D echo on 11 - 12 - 2022
16 -01
16 -01 140/80
17 -01 130/80
18 -01 130 / 70
19 -01 130 / 70
Treatment -
T pan 40 mg po/od( for serum aminotransferase elvation)
Metronidazole 500 mg ( antibiotic)
For Hypertension :- Temisartan 40 mg
Amlodipine 5 mg po OD
Follow up
- Bp charting advised 8 hourly.
Daibetic diet advised.
Comments
Post a Comment