A 42yr old Male with pain in epigastric region

A 42 year old male with  pain in epigastric region

  K.Rohith Dharma
Roll no- 165

This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.

Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

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 a diagnosis and treatment plan.

A 42 yr old male patient came to casuality with
Chief complaints:-
  Abdominal pain  since 3days.

  History of presenting illness:-
  Patient was apparently asympotamatic 5days back then he developed fever which was sudden in onset, intermittent in nature high grade subsided after taking medication associated with chills, rigor. 
   He developed epigastric pain 3 days back at night  for which he visited local hospital there rmp has given injection but pain was not subsided  by morning pain got aggrevated for which patient came here
     Which was  Sudden in onset, gradually progressive, non radiating , burning type. 
No H/o loose stools, nausea, vomiting. 
   
Past history :-
No similar complaints in the past. 
Not a known case of daibetes, hypertension, epilepsy
   
   Personal history :-
    Sleep -Adequate 
Appetite -Reduced
Bowel movements -regular
Bladder movements -regular 
Addictions -h/o alcohol intake since 10years and smoking since 10years 
No H/o allergies. 
  
 Family history :- 
No similar complaints in the family.

General Examination: 
Patient was conscious, coherent, cooperative well oriented to time place and person. 
No
pallor,icterus,cynosis,clubbing,lymphadenopathy,edema
Vitals: 
Temperature: Afebrile
Bp:100/80
PR:78bpm
RR:17/min
Spo2:98%at RA 
 
Systemic examination:
Abdomen
Inspection 
Shape - scaphoid
Umblicus - inverted
Abdominal movements - present
Stria marks absent 
No distended veins 
No visible peristalsis
No rebound tenderness 
Palpation
Liver and spleen are not palpable
Non tender soft 
Percussion
No shifting dullness,fluid thrill 
Auscultation
Bowel sounds heard 3-4/min
CVS : S1 S2 heard no murmur
CNS :NFAD
Respiratory : Normal vesicular breathe sounds 
BAE +
Investigations :
 Provisional diagnosis :
Viral pyrexia with thrombocytopenia with
 Alcoholic gastritis

 TREATMENT:-
INJ.PANTOP 40 MG IV OD
INJ.OPTINEURON 100 MG IN 100 ML IV OD
TAB .DOLO 650 MG OD SOS
INJ.NEOMOL 1GM IV NS
SYP.SUCRALFATE 10 ML BD
 IVF NS RL DNS @ 75 ml /hr.

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