A 42 YEAR OLD MALE WITH PAIN IN EPIGASTRIC REGION

42 yr old male with pain in epigastric region

January 12, 2022
V.Sai jaya Krishna
Roll no :- 137

This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.

Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

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 a diagnosis and treatment plan.
A 42 yr old male patient came to casuality with
Chief complaint:-
  Abdominal pain in epigastrium since 3days.
 

  History of presenting illness:-
  Patient was apparently assympotamatic 5days back then he developed fever which was sudden in onset, intermittent in nature, high grade subsided after taking medication associated with chills and rigor. 
  He developed epigastric pain 3 days back at Night for which he visited local hospital there Rmp has given injection but pain was not subsided , by morning pain got aggrevated for which patient came here. 
   Which was Sudden in onset, gradually progressive, non radiating , burning type. 
No H/o loose stools, nausea, vomiting. 
   
Past history :-
No similar complaints in the past. 
Not a known case of diabetes, hypertension, epilepsy, CHD. 
   
   Personal history :-
    Sleep -Adequate 
   Appetite -Reduced since 3days
   Bowel movements -regular
   Bladder movements -regular 
   Addictions -h/o alcohol intake since 10years     and smoking since 10years 
   No H/o allergies. 
  
 Family history :- 
No similar complaints in the family.

General Examination:-
Patient was conscious, coherent, cooperative well oriented to time place and person. 
No                                pallor,icterus,cynosis,clubbing,lymphadenopathy,edema.
Vitals:- 
Temperature: Afebrile
Bp:100/76
PR:78bpm
RR:17/min
Spo2:98%at RA 
 
Systemic examination :-
Abdomen- 
Inspection 
Shape - scaphoid 
Umbilicus - inverted
Abdominal movements - present
Stria marks - absent 
No distended veins
No visible peristalsis

Palpation :-
Gaurding or rigidity over abdomen.
 Liver and spleen are not palpable. 
Non tender, soft. 
 
Percussion :
No shifting dullness, fluid thrill. 
  
Auscultation :-
Bowel sounds not heard
CVS : S1 S2 heard no murmur
CNS : 
Conscious and normal speech
normal gait
crainal nerves are normal
sensory system is normal
motor system is normal
Respiratory system: Normal vesicular breath sounds .

   Investigations :-

PROVISIONAL DIAGNOSIS:-
Viral pyrexia with
 thrombocytopenia .

TREATMENT:-
INJ.PANTOP 40 MG IV OD
INJ.OPTINEURON 100 MG IN 100 ML IV OD
TAB .DOLO 650 MG OD 
INJ.NEOMOL 1GM IV NS
SYP.SUCRALFATE 10 ML BD
IVF NS RL DNS @ 75 ml /hr.

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