GENERAL MEDICINE ELOG

A 37 Year old with chief complaints of abdominal pain.


 *This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

*This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

*I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

 A 38 yr old male with chief complaints of abdominal pain. 

CASE

A 38 year old male came to OPD with chief complaints of abdominal pain since 4days.


HOPI

Patient  was apparently asymptomatic  4 days ago, then he developed abdominal pain associated with vomitings(10episodes per day which is non-bilious, non-projectile).

H/O constipation  since 4 days.

H/O bloating  since 4 days.

PAST HISTORY 

No similar complaints  in the past. 

Not a known case of diabetes mellitus, hypertension,  thyroid,  epilepsy. 

No history of previous surgeries. 

PERSONAL HISTORY 

DIET : mixed

APPETITE : decreased 

SLEEP : adequate 

BOWEL : constipation 

MICTURITION : no micturition since 4days.

FAMILY HISTORY 

Not relevant 

GENERAL EXAMINATION 

PALLOR : Absent

ICTERUS : Absent 

CYANOSIS : absent

CLUBBING : Absent

LYMPHADENOPATHY : Absent

EDEMA : Absent

VITALS

TEMPERATURE  : Afebrile

B. P : 160/140 mm of Hg

SPO2: 99

Respiratory rate : 22 cycles per minute. 


SYSTEMIC EXAMINATION 

G. I. T

Shape of abdomen : distended

Tenderness : yes 

Liver and spleen : not palpable 


C. V. S

S1 S2 heard, no murmers


RESPIRATORY SYSTEM

Position of trachea  : central. 

Dyspnoea : no

Wheeze : no 
































DIAGNOSIS

Acute necrotising pancreatitis. 



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