42 yr old male with pain in epigastric region
A.vishal
Roll no :- 148
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Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
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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 a diagnosis and treatment plan.
A 42 yr old male patient came to casuality with
Chief complaints:-
Abdominal pain in epigastrium since 3days.
Burning micturition since 3days
History of presenting illness:-
Patient was apparently assympotamatic 5days back then he developed fever which was sudden in onset, intermittent in nature high grade subsided after taking medication associated with chills, rigor.
He developed epigastric pain 3 days back at Night for which he visited local hospital there Rmp has given injection but pain was not subsided , by morning pain got aggrevated for which patient came here.
Which was Sudden in onset, gradually progressive, non radiating , burning type.
No H/o loose stools, nausea, vomiting.
Past history :-
No similar complaints in the past.
Not a known case of diabetes, hypertension, epilepsy, CHD.
Personal history :-
Sleep -Adequate
Appetite -Reduced since 3days
Bowel movements -regular
Bladder movements -regular
Addictions -h/o alcohol intake since 10years and smoking since 10years
No H/o allergies.
Family history :-
No similar complaints in the family.
General Examination:-
Patient was conscious, coherent, cooperative well oriented to time place and person.
No
pallor,icterus,cynosis,clubbing,lymphadenopathy,edema
Vitals:-
Temperature: Afebrile
Bp:100/80
PR:78bpm
RR:17/min
Spo2:98%at RA
Systemic examination :-
Abdomen-
Inspection
Shape - scaphoid
Umbilicus - inverted
Abdminal movements - present
Stria marks - absent
No distended veins
No visible peristalsis
No rebound tenderness
Palpation :-
Liver and spleen are not palpable.
Non tender, soft.
Percussion :
No shifting dullness, fluid thrill.
Auscultation :-
Bowel sounds heard 3-4/min
CVS : S1 S2 heard no murmur
CNS :NFAD
Respiratory : Normal vesicular breath sounds
BAE +
Investigations :-
TREATMENT:-
INJ.PANTOP 40 MG IV OD
INJ.OPTINEURON 100 MG IN 100 ML IV OD
TAB .DOLO 650 MG OD SOS
INJ.NEOMOL 1GM IV NS
SYP.SUCRALFATE 10 ML BD
IVF NS RL DNS @ 75 ml /hr.
