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





  



 

















Comments

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

    ReplyDelete

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