32 MALE pain abdomen under evaluation

 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.  


Chief complaints:

Fever since 7 days 

Pain abdomen since 7 days 

Burning micturition since 3 days

History of present illness:

Patient was apparently alright 7 days back then he  had fever which is sudden in onset,high grade and with chills and rigors, releived by taking medication.pain abdomen since 7 days in right hypochondriac,right lumbar, umbilical region,needle pricking type of pain , aggrevated during inspiration

H/o burning micturition since 3 days,no urgency , frequency, hesitancy.

No chest pain,sob, palpitations

No nausea, vomiting 

No loose stools 

No increased or decreased output 

Past history

Not k/c/o HTN,DM,TB, EPILEPSY,CVA

Family history:- not significant

Personal history:

Appetite:- normal

Diet:- mixed

Sleep :- adequate

B& B :- regular 

No addictions 

General examination:- 

Patient is conscious, coherent, cooperative well oriented to time place and person .

Moderately built, moderately nourished

Pallor:- absent 

Icterus:- absent 

Cyanosis:- absent 

Clubbing:- absent

Generalized lymphadenopathy:- absent

Bilateral pedal edema :- absent  







Vitals:- 

Bp:120/80 mmhg 

Pulse rate:-80 bpm 

RR:- 18 cycles per min

Temp :- 

Systemic examination:-

Cvs :- s1,s2 heard no murmurs

Cns :- no focal neurological deficits 

Abdomen :- soft ,non tender 

Rs: decreased air entry right side,no crepts,wheeze

Investigations:- 

 x - ray :-


USG 



Ecg


12/4/23 



Provisional diagnosis:

pain abdomen under evaluation ?pleuritis
Dyselectrolytemia(resolve)
Bilateral mild pleural effusion (right>left).

Treatment:-

T.PAN 40MG PO/OD

T.PCM 650 MG PO/TID

INJ.NEOMOL 1MG IV/ SOS

IV FLUIDS NS @50ML/HR

T.MYORIL 4MG PO/SOS

INJ.TRAMADOL 1 AMP IN100 ML NS/TID
  
MONITOR VITALS





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