27 year old male with pain abdomen
THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT
27 year old male painter by occupation was brought to causality with chief complaints of pain abdomen .
HOPI
Patient was apparently alright 40 days back then he developed pain and burning sensation in the abdomen which is squeezing type and diffuse all over the abdomen relieved after passing stools .
Stool - frequency: 3 times a day , Small amounts , non blood , normal in consistency, mucoid ,non foul smelling , non floating and yellow in color
Not associated with fever , vomitings ,headache, burning micturation, SOB , cold&cough, chills and rigors.
PAST HISTORY:
Not a know case of
hypertension ,
Diabetes,
Asthma ,
Tuberculosis,
Coronary heart disease
PERSONAL HISTORY:
Appetite : normal
Diet : mixed
Bowel and bladder : regular
Sleep : disturbed
Addictions :
alcohol - since 5 years
Daily since 3 years
180 ml
Tobacco- since 5 years
4-5 per day
FAMILY HISTORY:
No significant family history
GENERAL EXAMINATION:
Patient was conscious , coherent, cooperative and well oriented to time , place and person .
Thin built and Ill nourished
History of 10 kgs weight loss
Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy- absent
Edema - absent
SYSTEMIC EXAMINATION:
CVS -S1 S2 Heard
CNS - no focal neurologic deficit
RESPIRATORY - bilateral air entry present
PER ABDOMEN - tenderness in the left hypogastric region
VITALS :
TEMP: afebrile
BP - 110/70 mmhg
PR: 82bpm
RP: 20cpm
GRBS : 97 mg/dl
INVESTIGATIONS :
UGIE REPORT :
ESOPHAGUS: NO VARICES
STOMACH :ERYTHEMA OF THE ARTERIES , PROMINENT GASTRIC FOLDS IN BODY
IMPRESSION : MILD ANTRAL GASTRITIS
MICROBIOLOGICAL INVESTIGATIONS :
HIV1/2 rapid test _ non reactive
HBsAg rapid - negative
BLOOD SUGAR RANDOM : 97mg/dl
PROVISIONAL DIAGNOSIS : pseudocyst of pancreas
TREATMENT :
- tab Taxim 200mg
- tab PAN 40 mg
- INJ tramadol
- tab vit c
- tab buscopan
- tab ultracet
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