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.
32 year old male came to general medicine OPD chief complaints of :
Vomiting since 2 days.
Throught pain since 2 days.
Abdominal pain since 2 days.
Hopi:
Patient was apparently asymptomatic 2 days back and then he developed vomitings which were sudden in onset, gradually progressive, non projectile, non bilious, not blood tinged, content was just water because he hasn’t eaten in a couple of days, colour was black, 20 episodes in one night
, day before yesterday. No aggravating or relieving factors. . Patient also complained of abdominal pain since two days which was sudden in onset, non progressive, pins and needles type, diffuse type but it was more in the umbilical region. The pain from the umbilical region was radiating downwards toward the pubic symphysis. No aggravating or relieving factors.
No h/o of dysphagia
No h/o of flatulence
No h/o of anorexia
No h/o of constipation
No h/o of diarrhoea
No h/o of weight loss
No h/o of haemetemsis
No h/o of rectal bleeding
No h/o of melaena.
Past history:
In 2019 he came to our hospital with similar complaints of vomitings . He was treated and sent home.
Not k/c/o HTN,DM,TB, EPILEPSY,CVA, CVD
Family history:- not significant
Personal history:
Appetite:- normal
Diet:- mixed
Sleep :-inadequate due to present illness.
B& B :- regular
Addictions:He is an alcoholic since 20years.he consume 4 beers per day usually in the evenings.each beer of 750 ml. Last consumption was 2 days back. From last 4 days he was drinking 8 beers per day.
Past life : in 2004 he started drinking as he was a ambulance driver he should deal with dead body.in 2015 He stoped his driving work as he was drinking everyday and a lot. He stoped drinking for 5 years .he found a new job . And he again started drinking because of workers tension.
Dialy routine:
He wakes up at 6 in the morning and he drinks tea at 7am after bathing and has his break fast at 8 am he usually eats dosa and idly.then he goes to work at 10 am he packs lunch ahd takes it with him. He ets his lunch at 2 pm usually rice and curry at his work place. He returs back to his home at 6 pm and goes to his friends house at 7 pm and start drinking with his friends at some times eats in his friends house usually non veg some times he doesnt eat dinner . Usually he sleeps between 10 pm to 11 pm.
General examination:-
Patient is conscious, coherent, cooperative well oriented to time place and person .
Moderately built, moderately nourished
Pallor:- absent
Icterus:- absent
Cyanosis:- absent
Clubbing:- absent
Generalized lymphadenopathy:- absent
Bilateral pedal edema :- absent
Vitals:
Bp:120/80 mmhg
Pulse rate: 80 bpm
RR: 18 cycles per min
Grbs-124mg/dl
Temp: Afebrile
SYSTEMIC EXAMINATION:
P/A:
INSPECTION:
Shape of abdomen- scaphoid
Umbilicus- inverted
No Scars, Sinuses and engorged veins.
No visible palsations, peristalysis
Palpation:
No local rise of temp
tenderness - umblical region
No organomegaly
Percussion - No dullness
No Fluid thrill
No Shifting dullness
Ascultation
-Bowel sounds heard.
RESPIRATORY SYSTEM:
Bilateral air entry is present
Normal vesicular breath sounds are heard.
Provisional diagnosis:
Alcoholoic gastritis?
Investigations:
Final diagnosis:
Alcoholic gastritis
Treatment:1. INJ. PAN 40mg IV/OD
2.INJ.ZOFER 4mg IV/TID
3.INJ. Thiamine 200mg IV/BD
4. IV. Fluids NS@ 100ml/hr
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