General Medicine Case Discussion

April 20 , 2023

 General medicine case discussion

E LOG MEDICINE CASE

20/04/2023

This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 patient's clinical problems with collective current best evidence-based inputs.This e-log book also reflects my patient centered online learning protfolio and your valuable inputs on comment box is welcome.

Name : Mamatha. N

Roll no : 65

2020 Batch

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 comeup with Diagnosis and Treatment plan.

CASE DISCUSSION

Date of admission:17/04/2023

A 60 year old patient works as a village volunteer a resident of thanamcherla came to opd with 

CHIEF COMPLAINTS :

Abdominal distension since 7 days. 

History of presenting illness :

The patient was apparently asymptomatic 1 month ago. He then suddenly developed pain in the abdomen. Pain is picking type started from umbilicus and radiating to the left lumbar region. The pain is aggravating after eating and relieved when he sleeps. There are no associating factors. 

Abdominal distension started 7 days back which is insidious in onset and is diffuse type. Distension gradually progressed to the present size. 

Past history :

He developed jaundice 2 months back for which he used Ayurveda medication for 5 days . No improvement was seen so he went to Kmm where he was given medication for 15 days. 

No history of previous similar episodes. 

No history of previous surgeries. 

No history of TB, HTN, DM , Epilepsy, coronary vascular diseases. 

Personal history :

Sleep - Adequate 

Diet - Previously mixed diet, now vegan  

Appetite - Normal 

Bowel and bladder movements - Regular 

Allergies -None 

Addictions - Drinking natusara 90 ml per day since 3 years .

Family history :

No significant family history. 

General examination :

Conscious 

Coherent 

Moderately built 

Moderately nourished 

Well oriented to time, place and person. 

Pallor - Absent 

Icterus - Present 

 

Cyanosis - Absent 

Clubbing of fingers - Absent 

Lymphadenopathy - Absent 

Edema - Absent

Vitals :

Temperature - Normal 

Blood pressure - 130/ 70

Pulse- 72/ min

Breath rate - 13