Long case 1601006183
GENERAL MEDICINE FINAL PRACTICAL CASE:
Long case :
"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 patient's clinical problems with collective current best evidence based inputs.
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 clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
CASE :
A 55year old male, toddy climber by occupation came with complaints of pain in abdomen and fever.
CHIEF COMPLAINTS:
A 55 year old male patient, toddy climber by occupation, resident of miryalguda, came with complaints of :
1) Pain abdomen since 10 days.
2) Fever since 7 days.
3) Decreased appetite since 1 week.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 10 days back and later developed -
1) Severe pain abdomen in the right upper quadrant region of abdomen, which was sudden in onset, gradually progressive, dragging type and non radiating. It is aggravated on standing position and relieved for sometime upon taking medication.
2) He later developed fever since 1 week which was high grade, continuous type and associated with chills and rigor. It is not associated with cold, cough, shortness of breath, neck pain, giddiness, headache and sweating. It is relieved mildly upon taking medications.
-No complaints of chestpain, palpitations and burning micturition.
HISTORY OF PAST ILLNESS:
Patient was admitted in the hospital for 3 days with similar complaints 14 days back and was given IV antibiotics for 3 days.
There is no history of DM/HTN/EPILEPSY/ASTHMA/CVA/CAD.
TREATMENT HISTORY :
3 day high - dose antibiotics course given 14 days back.
PERSONAL HISTORY:
Appetite - Decreased since 1 week
Sleep - Decreased due to pain
Bowel and bladder - Regular
Micturition - Normal
Addictions - Toddy consumption - 1 bottle/day since 30 years
Tobacco in the form of beedi - 10/day
FAMILY HISTORY:
There is no relavent family history
GENERAL PHYSICAL EXAMINATION:
The patient is conscious, coherent and cooperative, sitting comfortably on the bed.
- He is well oriented to time, place and person.
- He is moderately built and moderately nourished.
Vitals:
Temperature chart -
