56 year old patient with pain in abdomen





 This is an E-log book to discuss  our patient's de-identified health data shared after taking his guardian sign informed consent.Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problem with collective current best evidence based inputs.This E-log book also reflect my patient  centered online learning portfolio.


A 56 year old man came to OPD with the chief complaint of pain in abdomen, abdominal distension and decreased urine output since 4 days.

Patient was apparently asymptomatic 4 days back,then he developed pain in abdomen (upper abdominal region).He complained of distension of abdomen since 4 days.

No history of nausea, vomitings and constipation.last alcohol consumption 5 days back.


HISTORY of Past Illness 


Patient is alcoholic 

Patient has wrist pain since 2 years.

Not a known case of diabetes mellitus, hypertension and CAD.


PERSONAL HISTORY


Diet: mixed 


Appetite:normal 


Bowel movements: normal 


Addictions: alcohol


 Family history;- 

No similar past family history 


GENERAL EXAMINATION

Patient is conscious, coherent, cooperative, well oriented to time, place and person.


VITALS 


BP - 110/90mmhg


Pressure - 78bpm


Temperature-afebrile 


Pulse rate - 102


Resp rate - 20 cpm 


GRBS -94


Spo2 - 100% 



SYSTEMIC EXAMINATION


RS-bae+

CVS- S1 , S2+


Diagnosis:- 
Spleenomegaly with ascites 
























Treatment:- 
Tab dolo 650 mg TID
Injection neomol IV
Inj pan 40 mg
Monitor bp, spo2 and temperature 
Inj vit B12 1500ml mg in 100ml NS over 1hr.



 





Comments

Post a Comment

Popular posts from this blog

CHRONIC PANCREATITIS WITH PSEUDOCYST

Image
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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .   A 27 year old male patient who is electrician by occupation came with a chief compliant of abdominal pain since 3 months HISTORY OF PRESENT ILLNESS :- Normal routine of patient: He used to wake up around 7 in the morning and have breakfast (rice) at 9 am and then go to work and return around 8 in the night.He used to consume alcohol almost everyday Patient was asymptomatic three months back and then developed a mild diffuse abdominal pain in the left hypochondrium region Later
Read more

A 19 y/o make with fever and body pain

Image
  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 -centered online learning portfolio and your valuable inputs on the comment box" A 19yr old male patient came to the opd with chief complaints of fever Since 1 week. HOPI:- Patient was Apparently asymptomatic 1 week back then he developed fever with chills which is high grade ,sudden in onset & associated with body pains .Relieved on medication. 2 days back he was taken to outside hospital there his platelet count was 1,29,000 cells/cumm, yesterday they were 1,32,000cells/cumm.Today they were 98,000cells/ cumm. No h/o Loose stools, vomitings, No h/o
Read more

50 YEAR OLD MALE PATIENT WITH FEVER AND SOB

Image
  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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome . A 50 year old male patient who is farmer by occupation came with a chief complaints of fever since ten days,lethargy, blood in saliva since 3 days and SOB since 2 days. Patient was asymptomatic 10 days back and later developed low grade fever of intermittent type which was relived on medication and was not associated with chills and rigor.The patient was lethargic so he consulted a local doctor and was diagnosed to have Dengue NS1 His platelet count was :  44,000 on day 1   22,
Read more