Gen med case presentation;
Oct 30,2021
Name;Ramya reddy pebbeti.
Roll no;105 .
This is 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 patients’ clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient centred online learning portfolio and your valuable inputs on comment box is welcome.
I’ve 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
Following is the view of my case :
CASE PRESENTATION ;
DOA; 29/10/21
Chief complaints; A 32 yr old male, who is lorry driver by occupation came to the opd with C/O
#PAIN abdomen since yesterday (28/10/21)
#Vomitings 2 episodes on 28/10/21
HOPI:
patient was apparently normal 2 days ago, then he developed pain abdomen from yesterday mrng which was insidious in onset, gradually progressive and it is localized to epigastric and periumbilical region and it was squeezing type of pain and non radiating type, aggravating on eating and on drinking , no relieving factors.
There is associated nausea and vomiting
Vomiting - 2 episodes, non projectile, non- bilious, and contents are food particles.
no h/O fever, cough, constipation
PAST HISTORY ;
he had similar complaints 4 yrs back for which he got treated.
Again he had similar complaints in September after having alcohol, for which he got treated here.
Not a k/c/O DM, HTN, asthma, epilepsyepilepsy, CAD.
No surgical history
PERSONAL HISTORY:
DIET: mixed
Appetite; normal
Bowel and bladder; regular
Sleep ; adequate
No known allergies
Addictions; occasionally he takes alcohol.
FAMILY HISTORY: not significant.
GENERAL EXAMINATION;
he is conscious, coherent, cooperative, well oriented to time, place, person .
He is moderately built and moderately Nourished
Vitals;
Temp; Afebrile
PR ;90 bpm
RR; 18 cpm
BP;130/90 mm of Hg
NO pallor, icterus, clubbing, lymphadenopathy, edema
SYSTEMIC EXAMINATION;
RS; BAE+
CVS; S1, S2 heard
CNS: Intact
P/A ; Soft and tenderness is present in epigastric region and around Umbilicus
Bowel sounds are heard
PROVISIONAL DIAGNOSIS;
ACUTE PANCREATITIS secondary to Alcohol
Treatment;
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