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 55 year old male patient who is Barber by occupation came to the OPD with chief complaints of abdominal pain since 2 days
HOPI:
Patient was apparently asymptomatic 20 years back then he developed abdominal pain which was diagnosed as intestinal perforation for that he undergone surgery. He developed abdominal pain from 2 days which is sudden onset, progressive,dragging type of pain, On day 1 the pain is radiating to chest on lying position.On day 2 pain is limited to abdomen. There is no history of fever, vomiting,nausea,Shortness of breath.
Past History:
Not a known case of diabetes,Hypertension, tuberculosis,epilepsy, Asthma.
Personal History:
Diet:mixed
Sleep: disturbed due to pain
Appetite:normal
Bowel bladder movements: regular
Addictions: alcohol consumption since 25 years 90 per day
Family History:
No significant
General Examination:
Patient is conscious,coherent and cooperative well oriented to time,place,person
No signs of pallor,icterus,clubbing,cyanosis,lymphadenopathy,Edema.
Vitals:
Temp:afebrile
Pr:98bpm
Rr:18cpm
Bp:140/100
Spo2:98%
Systemic examination:
Cvs: S1,S2 heard,no murmurs heard
Rs:BAE +,NVBS heard
Abdomen Examination:
Inspection: scar present on the epigastric region,no Dilated veins are seen.
On palpation:
Abdomen is Soft,tenderness present in epigastric region and there is a mild Rigidity present in the epigastric region.
On auscultation:
Bowel sounds are heard
Investigations:
X-Ray
LFT:
TB:2.18
DB:0.79
AST:51
ALT:27
ALP:176
TP:7.5
ALB:4.5
RFT
Urea:20
Creatinine:0.9
Na:139
K:3.2
CL:103
S.amylase:579.4
Diagnosis:
Acute Pancreatitis
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