General medicine elog

 A 48 YEAR OLD MALE CAME WITH PAIN ABDOMEN AND LOW BACK PAIN


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

CASE SHEET:

Chief complaints:

A 48 year old male, industrial worker by occupation came to OPD with chief complaints of:
-pain abdomen since 5 years
-constipation since 5 years
-pain in neck region since 1 year
-low back pain since 1 year
-shortness of breath since 1 year

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 5 years back. He then developed pain abdomen which was left side and umbilical region each episode lasted for 4 to 5 hours.

 He also had complaint of constipation since 5 years.No history of blood in stools.

He also complained about neck pain on back side since 1 year which aggravated on movement of head.

Associated diseases:
Not significant

Past history:
 Not significant

PERSONAL HISTORY: 

Diet: Mixed
Bowel habits: Constipation since 5 years
Micturition: Normal
Appetite: Decreased
Addictions: Chronic smoker since 20 years
No history of asthma, allergies, tuberculosis, coronary artery disease

Family history:

Not significant

Drug history: 
Pan 40
Clavum 625 
Montek-LC (10/5)

GENERAL EXAMINATION: 

No pallor


No icterus


No cyanosis


No clubbing
No lymphadenopathy
No pedal edema
No dehydration







Vitals:

Temperature: afebrile
Pulse: 78 beats per minute
Blood pressure:110/80 mm of Hg
SPO2:96%

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills
Cardiac sounds: S1, S2 heard
Cardiac murmurs: no

Respiratory system:

No Dyspnea
No wheezing
Position of trachea: Central
Breath sounds heard: vesicular

Abdomen:
 
Shape: 

Tenderness: right iliac fossa and umbilical region
No palpable mass
Non palpable liver
Non palpable spleen
Bruits: absent
Bowel sounds: absent

Central nervous system: 

Conscious
Speech: normal

INVESTIGATIONS:
USG:

ECG:



Provisional Diagnosis :
         Pain abdomen under evaluation, cervical spondylosisspondylosis.

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