36 Year Old Male with vomitings and Abdominal pain

 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. 



This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment


A 36 year old male salesman by occupation from West Bengal came to OPD.

Chief complaints:
Recurrent episodes of vomitings associated with abdominal pain since 2 months

History of present illness:

●Patient was apparently asymptomatic 2 months back,then he developed vomitings after 3-4 hours of taking food which was insidious in onset and is gradually progressive.
The contents are food particles which is non blood stained and non bile stained.
Aggrevated on taking food and no relieving factors. 
The vomiting are non projectile in nature.
Patient is having three to four episodes of vomitings a day because of which patient avoided to eat food regularly and landed up in fatigue , weight loss.


●Patient complaints of pain in the abdomen since 2 months which is diffuse(in epigastric,umbilical,hypogastric region) , squeezing type which is insidious in onset and gradually progressive non radiating to any other parts.

H/o nausea ,giddiness , weakness , constipation .

Accidentally jaundice was diagnosed before 2 months for which he took medication.

No H/o headache , fever , cold , cough , shortness of breath ,Orthopnea.
No H/o palpitations, chest pain , heart burn
No H/o hematemesis , heamatochesia , malena 

Past history:
No similar complaints in past
No h/o Diabetes, hypertension , TB , Asthama and  epilepsy

Family history:
No significant family history

Personal history:

Diet -mixed

Appetite- normal

Sleep - disturbed due to pain in abdomen 

Bowel and bladder - bowel movements are irregular ( i.e once in every 5 -6 days) but bladder function is normal

Addictions- have habit of chewing tobbaco


Treatment history:
 No significant treatment history

Vitals:

Temperature- afebrile
Pulse rate - 72bpm 
RR - 15 cpm
Bp - 90/60 mm hg 
Spo2 - 98

General Examination:
Patient is conscious, cohorent , cooperative well oriented time,place and person.
He is thin built and under nourished

Pallor- present
Icterus- absent 
Clubbing -absent
Cyanosis -absent 
Lymphadenopathy -absent 
Edema -absent


Physical Examination:
Sunken eyes due to loss of subcutaneous fat around orbits
Muscle wasting
Loss of weight and subcutaneous fat
Temporalis muscle atrophy
These all are suggestive of malnutrition

      




Systemic examination:

Abdominal examination

Inspection 
The shape is scaphoid
Umbilicus is in central
No flank fullness
The skin is normal
No dilated and engorged veins
No scars
Abdominal movements are normal

Palpation:
No local raise of temperature
A mass can be palpable in the right periumbilical region
No palpable liver and spleen so , no hepatomegaly and splenomegaly.


Percussion:
No fluid thrill
No shifting dullness

Ascultation:
Increased bowel sounds

CVS :
S1 S2 heard
No other murmurs

CNS :
No focal neurological deficit

Respiratory:
Normal vesicular breath sounds heard.

Provisional diagnosis:
Abdominal obstruction 

Investigations:
April 21








Diagnosis:
Intestinal Obstruction

Treatment:
Tab RAZO 40mg OD
Monitor vitals 6 hourly

Comments

Post a Comment

Popular posts from this blog

60 /Female with slowness of movement/ Long case

Image
60 /Female with slowness of movement/ 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.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome." Chief compliants :  1) Slowness of movements since 1 year . 2) Involuntary movements of the Left upper limb. 3) Slowness in speech since 1 year. History of present illness :  60 year old female,who is a mother of 3 children (  1 son and 2 daughters ), labour by occupation ( goes to agriculture field ) was apparently asymptomatic 1 year back, then developed Slowness of movements which was insidious onset, gradually p
Read more

54 Y OLD M WITH VOMITINGS,SOB,FEVER

Image
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 Patient came to causality with complaints of Fever since 5 days SOB since 5 days Vomiting for 3 days The patient was apparently asymptomatic 5 days back then he developed fever, high grade, not relieved with medication , associated with chills and rigors. SOB since 5 days, grade III , no orthopnea , pnd. Also presents with vomitings since 3 days, non bilious, non blood stained , watery, 2-3 episodes. Ulcer over left foot,since 4 months, associated with edema of foot,  H/o abscess drainage??? New bleb notes since 2 days. K/C/O DM II since 14 years, on Metformin 500 mg and Glimi
Read more

48/M WITH EQUINE GAIT PARAPARESIS 2 MONTHS HBV+

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  c omprehending clinical data including history, clinical findings investigations and come up with diagnosis and treatment plan UNIT 1  MEDICAL WARD   DOA:04/06/23 A 48 year old male farmer by occupation,resident of Nalgonda came to the opd with chief complaints of  WEAKNESS OF BOTH LOWER LIMBS SINCE 6MONTHS BURNING SENSATION OF FEET SI
Read more