A 38years old male with pain abdomen.

 THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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 years old male came to the opd with chief complaint of pain in the upper abdomen since 5years.

History of presenting illness:

He was apparently asymptomatic 5years back the he developed pain in the upper abdomen which was sudden in onset and gradually progressive ,dragging type of pain which was radiating to back.Aggravates on taking food and alcohol and relieved temporarily on medication.

On 13th of November he had a multiple episode of vomiting after having food intially vomiting contain food particles later it contain water.vomiting associated with weakness and giddiness.

Abdominal pain associated with vomiting.initially the pain used to be one in every 3months but from 6 months the pain occurs one or twice in every month.

constipation present.

Presence of white patches in the buccal mucosa.

Bilateral lower limb pain

History of hypertension since 5years.

Past history:

16 year back(when he was 12 years) he had a history of jaundice which was subsided by taking medication(bilirubin levels was 3.5mg/dl.)

At 12 year of age he had sustain injury to the nose while playing foot ball and then DNS is diagnosed for which septoplasty was not done.

At 12 year he noticed a lesion over his left forearm which was a fungal infection but treated as leprosy and he developed adverse drug reaction for the treatment.

At 12 year he was diagnosed with hemorrhoids.

At 15years of age he was having mild pain in the right iliac region but he neglected it for 6 months but it is increasing in intensity so he went to hospital there he diagnosed with Appendicitis and Appendisectomy was done.

5 year back he had a history of depression and insomnia for which he consulted psychiatrist and medication were prescribed but it didn’t subsided with the medication.

No history of Diabetes, Tuberculosis,Asthma,CVD.

Personal history:

He is married

Diet-mixed

Appetite-Decreased

Sleep-inadequate 

Bladder-regular

Bowel-irregular(constipation)

Addictions-Consumes alcohol everyday(approximately 180-360ml) since 10years but stopped having from July 13.

                 Somking from last 20years intially he used to smoke 1-2 cigarettes/day but later he started smoking 1-2 packs per day.

Allergies-none.

Family history:

Not significant.

General examination:

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy:absent

Pedal edema:absent

 

Vitals:

Temperature - 94*F

PR :- 80 bpm

RR :-16 cpm

BP :- 110/70 mm Hg

Systemic examination:

CVS : S1S2 heard

RS:15cpm

CNS:No focal neurological deficit.

P/A: inspection-not distended,umbilicus inverted,no discharging sinuses and scar over right iliac fossa(appendisectomy scar)

Palpation:mild tenderness in left hypocondrium and epigastric region.

Percussion:-tympanic 

Auscultation:-bowel sounds are audible.

 

Investigations:

Provisional Diagnosis:

Chronic pancreatitis 

Treatment:

Ultracet 

 

Discharge summary: