lekhana

51yrs old male with complaints of pain abdomen and vomitings



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 I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a  diagnosis and treatment plan.
 This is a case of 51year old male farmer by occupation Has come to the op with chief complaints of 

1) Pain abdomen since today morning 

2) Vomiting

HOPI:-

Patient was appatently asymptomatic 3years back.He developed pain abdomen and vomitings for which he was diagnosed as acute pancreatitis at private hospital at nalgonda sanjeevani hospital, was admitted for 3days and subsided and got discharged. After 7 months he came to KIMS narketpally and got treated for some and got discharged at request and went to other hospital. Now patient came with abdominal discomfort and vomitings from today morning 8am

Past history:-

 Is a known case of Dm is on Rx since 10-12years

Rx - T Glim m1 and T voglibose and glim m1

Is not a known case of HTN/CAD/Epilepsy

Is a known alcoholic occasional from 30years .stopped alcohol consumption since 3years

Personal history:-

Appetite -normal

Diet - Mixed

Bowels - regular

Micturition - Normal

No allergies

Family history:-

Not significant

General exmination

 Patient is consious , coherent , well oriented to time , place and person

Patient is moderatley built and nourished

Pallor - no

Icterus - no

Cyanosis - no

Clubbing - no

Lympadenopathy- no

Malnutrition - no

Temp -98.6f

PR- 82Bpm

RR- 16cpm

Bp - 120/80

Spo2 - 98%

GRBS - 102 mg%

CVS -S1 S2 +ve

RS - Bae +ve

PS - Soft and non tender

CNS - Higher motore functions intact

DIAGNOSIS:-

Pain abdomen under evaluation

Investigations


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