General medicine elog

 General medicine elog 

Hi , I am Anamika Maiti ,3rd semester student.  This is an online elog book to discuss our patients health data after taking his consent.  This also reflects my patient centered online learning portfolio.

A CASE OF ABDOMINAL PAIN SINCE 2 YEARS

A 34 year old male patient, barber by profession and a resident of koochbihar(WB) came to the OPD with chief complaint of :

Loose stools since 2 years ,abdominal pain since 2 years ,

Reduced appetite since 2 months,

Burning sensation after food intake.

HISTORY OF PRESENT ILLNESS:

Loose stools since 2 years once in 2 days(food particles),

Diffuse abdominal pain since 2 years ,

Rashes over upper and lower limbs and itching since 3 months,

Cough since 2 months,

Reduced appetite since 2 months,

Burning sensation after food intake.

HISTORY OF PAST ILLNESS:

 Not a k/c/o HTN, DM, CAD, CVA, Asthma, TB.

PERSONAL HISTORY :

Married 

Occupation - barber

Appetite - reduced 

Diet - mixed 

Bowels- Loose stools

Micturition- normal 

Addictions- alcohol  occasionally since 10 years,

                      Smoking occasionally since 10 years (1 cigar/day).

FAMILY HISTORY: no relevant family history 

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative. 

No pallor, icterus, cyanosis , clubbing of fingers, lymphadenopathy and oedema of feet.

Vitals:

Temperature- 98.6F

BP - 110/80 mmHg

PR- 82 bpm

RR- 16 cpm

SpO2 - 98% 

SYSTEMIC EXAMINATION 

CVS : S1S2 heard , No murmurs

RS : dyspnoea- no

Wheeze - no

Position of Trachea- central

Breath sounds- vesicular

ABDOMEN 

Shape- scaphoid

Non tender

No palpable mass

Hernial orifices- normal 

No free fluid

Liver- not palpable 

Spleen- not palpable 

Bowel sounds - no

INVESTIGATIONS 

USG of abdomen 

ECG

Chest X-RAY 

Hemogram

Microscopy of stool

Colonoscopy