A 55year old male patient with lower abdomen pain

July 14,2023

Hi,I am Athram Divya Sri 5th semester student.This is an online elog book to discuss our patient health data after taking his consent.this also reflect my patient centered online learning portfolio. 

                      CASE SHEET

CHIEF COMPLAINTS:

A 55 year old male patient resident of yadadri , farmer by occupation came to OPD with chief complaints of  pain in the lower abdomen since 3days


HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 4 days ago then he developed pain in the epigastric region associated with vomiting 2episodes.vomiting had food particles as content and coconut water
Pain was sudden in onset and gradually progressive on and off episodes and burning sensation on the perumbilical and constipation since 6days


PAST HISTORY:
  N/K/C/O  hypertension, diabetes mellitus, thyroid disorders, asthma, epilepsy. 
Previously admitted in the department of general medicine for alcoholic liver disease alcohol withdrawal hyperactive delirium secondary to drug induced
(Promethazine50mg) and was discharged on 8-01-23

PERSONAL HISTORY:
Married
Farmer by occupation
 Loss of Appetite
Mixed diet
Constipation since 6days
Normal micturition
No known allergies 
Addictions - regular consumption of alcohol and he is a smoker

FAMILIES HISTORY:

No significant family history 

GENERAL EXAMINATION:

Pt was conscious, coherent and cooperative 
Moderately built and nourished 
Pallor- absent
Icterus- Absent
Cyanosis- Absent
Clubbing- Absent
Lymphadenopathy- Absent
Pedal oedema- Absent



Vitals:

Temperature : 98.6F
Pulse rate : 99/min
Respiratory rate : 18 per minute 
Blood pressure : 130/80 mm of Hg
sPO2 : 99% 

Systemic Examination 
Cardiovascular System-
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs
Respiratory System 
 no dyspnea 
No wheezing
central trachea
Abdomen
Obese shaped abdomen 
  tenderness present 
No palpable mass
Non palpable liver and spleen
CNS
Patient was conscious
Normal speech


INVESTIGATION:
ECG:

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