42 yr Male with Vomiting,loose motion since 3 days
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
42 yr old Male patient came to casualty with chief complaints of
1.vomitings since 3 days
2.loose motions (3-4 episodes)/day since 3 days
3.Shortness of breath since evening (on 3/12/23)
4.chest pain since 3 hours(on 3/12/23)
HOPI:
Patient was apparently asymptomatic 3 days ago then he developed vomitings (3-4 episodes/day) which is Non bilious,Non projectile and blood tinged.
In the same day he developed loose motions 3-4 episodes/day which is associated with blood clots
After 2 days he developed shortness of breath which is insidious in onset and gradually progressed to grade 2.
On the same day he developed chest pain which is sudden in onset,non radiating and is of burning type for which he came to our hospital
Past history:
Known case of epilepsy (3 episodes since 3 yrs) last episode 1 yr back for which he used medications for 6months
Not a k/c/o DM,Asthma,HTN,TB,CVD,CAD
Personal history:
Diet:Mixed
Appetite:Normal
Sleep: Adequate
Bowel and bladder movements: Irregular
H/o consumption of alcohol (90ml/day since 15 yrs
H/o tobacco chewing since 14 yrs (1 pack/2days)
No h/o smoking
General Examination:
Pt is conscious,coherent and cooperative
Moderately built and nourished
No pallor,icterus, cyanosis, clubbing, Lymphadenopathy and edema
Vitals:
Bp:110/70 mmhg
PR:82bpm
RR:17cpm
Spo2:98%on RA
Clinical Images:
Systemic Examination:
CVS:
Jvp not raised
Inspection:
Shape of chest - elliptical
No visible pulsations
No engorged veins and scars
Apical impulse not visible
Palpation:
Apex beat present over the left 5th intercostal space 1cm medial to midclavicular line
No parasternal heave
No precordial thrill
No dilated veins
Auscultation:
S1 S2 heard ,No murmurs
Respiratory system:
Upper respiratory tract - normal
Lower respiratory tract:
Inspection:
Chest bilaterally symmetrical,
Shape- elliptical
Trachea- midline
Palpation:
Trachea is central
Normal chest movements
Percussion: in sitting postion
Rt. Lt
Supraclavicular. N(resonant). N
Infraclavicular. N. N
Mammary region. N. N
Axillary region. N. N
Infra axillary region. N. N
Supra scapular region. N N
Interscapular region. N. N.
Infrascapular region. N. N
Auscultation:
Normal vesicular breath sounds
No added sounds
Vocal resonance is normal
Per Abdomen:
Inspection:
Shape - scaphoid
Umbilicus - inverted
All quadrants moves equally with respiration
Palpation:
All inspectory findings are confirmed
No local rise of temperature
Abdomen is soft and non tender
spleen and liver -not palpable
No other palpable masses
Hernial orifice are free
Percussion:Resonant
Auscultation:
Bowel sounds heard
Pectus Excavatum is seen
CNS :
Higher motor functions - intact
Cranial nerves - intact
Motor system:
Rt- UL. LL. Lt- UL. LL
Bulk - normal N. N. N
Tone - N. N. N. N
Power - 5/5. 5/5. 5/5. 5/5
Reflexes:
UL. LL
Biceps. 2+. 2+
Triceps. 2+. 2+
Supinator. 2+. 2+
Knee 2+. 2+
Ankle. 2+. 2+
Sensory system: intact
Co ordination is present
Gait is normal
No Cerebellar signs
No signs of meningeal irritation
Investigations:
ECG
USG
Comments
Post a Comment