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
Please remove the consent form from the case report. It's supposed to be kept separately and not meant tho be uploaded here.
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