55 yr old male with pain abdomen
This is an online E log book to discuss our patient's 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 available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome.
I've 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.
E. Gnana Prasanna
Roll No - 01
Admn : 166029
PATIENT CAME TO THE OPD,WITH THE CHIEF COMPLAINTS OF :
Giddiness since 10 days
Pain abdomen since 10 days
Neck pain since 10 days
Patient was apparently alright 10 days back then he had pain in epigastric region, squeezing type and went to local hospital and not relieved by taking medication.
2 episodes of vomitings 8 days back. Nausea present
Giddiness since 10 days. No loss of consciousness. Neck pain since 10 days, non radiating and no restriction of neck movements. Burning micturition present. No decreased urine output. No H/O Fever, cold, cough
K/C/O HTN Since 2 years (on telma 40mg)
Not a k/c/o DM,TB, Epilepsy, Asthma
Right varicose veins operation 9 years back
Left varicose veins operation 1 year back
Bilateral Renal calculi operation 9 years back
PERSONAL HISTORY :
Appetite -Normal
Diet - Mixed
Sleep - adequate
Bowel and bladder movements -Regular
Addictions:No addictions
Allergies : No allergies
GENERAL EXAMINATION:
Patient is conscious ,coherent , cooperative, thinly Built and Moderately Nourished .
He was examined under well lit room with consent taken
Temp: 98.4F
BP : 100/80 mmHg
PR : 78bpm
RR : 20cpm
Pallor : absent
Icterus : absent
Cyanosis: absent
Clubbing : absent
Lymphadenopathy : absent
Edema : absent
CVS : S1 S2 + ,no murmurs
RS : Bilateral air entry present, normal air entry present
P/A : Soft and non tender, no organomegaly
CNS: NFD
INVESTIGATIONS
19/01/23
HEMOGRAM
Hemoglobin: 15.7
TLC: 8,000
[N/L/E/M/B (%)- 45/45/04/06/00]
Platelet: 2.25
MCV: 85.4
MCH: 29.3
PCV: 45.8
RBC COUNT: 5.36
ELECTROLYTES
Na: 136
Cl: 98
K: 4.9
Ca ionised: 0.89
RBS-94
RENAL FUNCTION TESTS
Urea: 43
Creatinine: 1.2
Uric acid:4.4
LIVER FUNCTION TESTS
Total Bilirubin: 1.27
Direct Bilirubin: 0.35
SGOT(AST): 14
SGPT(ALT): 10
ALP: 119
Total Protein: 7.5
Albumin: 4.4
A/G: 1.42
Serology - Negative
TREATMENT-
T.TELMISARTAN 40MG PO OD
Comments