46yr old male teacher by occupation came to opd with c/o Pain and Burning sensation of abdomen and Dyspepsia

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident 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 46 yr old male teacher by occupation from West Bengal  came to opd with 
CHEIF COMPLAINTS: 
Pain and Burning sensation in Abdomen 
since 10 yrs 
Diarrhoea since 5 months 
Weakness and weight loss 


HOPI : 
Patient was apparently asymptomatic 10yrs back and then he developed  pain and burning sensation in the abdomen with altered bowel habits  , for which he went to a local hospital and later diagnosed with Cholelithiasis for which  he has undergone cholecystectomy,

 After the surgery he again started to get pain in the abdomen and diarrhoea,which was aggrevated on eating spicy foods and controlled by medication after that there was an increased episodes of diarrhoea and pain in the abdomen since 5 months 
He also has fear to be alone in a room and fear to walk alone outside since 3 yrs 




DAILY ROUTINE : 
Wokes up at 6:00 AM and complete his chores , Goes to school by 9:00AM , Takes tea and breakfast at 10:00AM 
Lunch at 12:30PM Mostly vegetable curries and Rice 
Chewing tobacco between 5:00 to 6:00pm 
Comes home by 6:00PM 
Eats Dinner at 8:00PM 



PAST HISTORY: 
He has similar complaints in the past 
 He is a Kown case of Hypertension since 3 yrs 
under treatment with T.MET XL 12.5 mg 
He is not a known case of DM, EPILEPSY,TB ,ASTHAMA 
He was on Amitriptyline 12.5 mg continous from 15 days 
Cholecystectomy was done 5yrs back 



FAMILY HISTORY: 
His father has hemorrhoids , Bleeding is present 



PERSONAL HISTORY: 
DIET : mixed 
Apettite: Normal 
Bowel movements: Irregular
Bladder : Normal 
Sleep : adequate
No known drug and food Allergies
Has a Habit of Chewing Tobacco and betel leafs since he was 17yrs 

GENERAL EXAMINATION: 
Pt was conscious, coherent, co operative 
Well built and Well Nourished 

Pallor , Icterus , Clubbing ,cyanosis ,
 Generalised lymphadenopathy and Edema are ABSENT 


VITALS 
TEMP :  98.6 
PR : 82 beats /Min 
RR : 20 cycles /Min 
BP : 140/90 mm Hg 


SYSTEMIC EXAMINATION : 
ABDOMEN : Soft and Non Tender Bowel sounds heard 
CVS : S1 AND S2 HEARD No murmurs 
CNS : No focal Neurological Deficit
RESPIRATORY SYSTEM: NVBS , TRACHEA CENTRAL 
INVESTIGATIONS :
ULTRASONOGRAPHY : 
COLONOSCOPY: 






Provisonal Diagnosis : 
Chronic Diarrhoea, Internal Hemorrhoids 

Treatment:








Comments

Post a Comment

Popular posts from this blog

MY EXPERIENCE IN MEDICINE DEPARTMENT

 This in D.Naga Sai Rohith Naidu  a medical student from India. Welcome to my blog .I came to postings when I am in my 3rd semester i don't know how to take a case, what are the things to ask ,how to examine a patient ,how to present myself  towards a patient how to present a case, slowly with my pgs and with  my hod  help i learned how to take a proper history of a patient . As it is very clear that Case taking and history taking are fundamental aspects of the medical  practice. They play a crucial role in gathering relevant information about a patient's condition, which helps in making an accurate diagnosis and developing an appropriate treatment plan. With the help of this Case taking and history taking provided me an opportunity  to establish a rapport with the patients.  I established a patient and doctor relationship which feels so excited  to me. This blog system helps us to keep every information together in a place which is very useful. NOTE: THIS IS AN ONLINE E LOGBOO
Read more

25 yr old male cane to opd with blood in stools and shortness of breath

Image
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 centered online learning portfolio and your valuable inputs on comment box is welcome.  A 25 yr old male patient from narketpally runs a wine shop came to opd CHEIF COMPLAINTS:   Blood in stools since 12 days  , Shortness of Breath since 7 days , Headache since 9 days. HISTORY OF PRESENTING ILLNESS:  Patient was apparently asyptomatic 5 months back then he noticed blood before and after passing stools for which he took medication( unknown) . From 12days he again complains of hard blood in stools associated with an episode of vomiting,not associated with pain in the
Read more

70 YR OLD MALE WITH CHEST PAIN COUGH SHORTNESS OF BREATH

Image
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident 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.   70 year old male came  to OPD with  CHEIF COMPLAINTS :   1.Chest Pain since 10 days  2.Cough since 10 days  3.Shortness of breath  since 8-10 days 4. Fever since 1 week Hopi- Patient was apparently asymptomat
Read more