27 year old male with pain abdomen


 THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT 

27 year old male painter by occupation was brought to causality with chief complaints of pain abdomen .

HOPI 

Patient was apparently alright 40 days back then he developed pain and burning sensation in the abdomen which is squeezing type and diffuse all over the abdomen relieved after passing stools .
Stool - frequency: 3 times a day , Small amounts , non blood , normal in consistency, mucoid ,non foul smelling , non floating and yellow in color 

Not associated with fever , vomitings ,headache, burning micturation, SOB , cold&cough, chills and rigors.

PAST HISTORY: 

Not a know case of 
hypertension  ,
 Diabetes,
Asthma ,
Tuberculosis,
Coronary heart disease 

PERSONAL HISTORY: 

Appetite : normal 
Diet : mixed 
Bowel and bladder : regular 
Sleep : disturbed 
Addictions :
 alcohol - since 5 years 
                     Daily since 3 years 
                     180 ml

Tobacco- since 5 years 
                4-5 per day 

FAMILY HISTORY: 
 No significant family history 

GENERAL EXAMINATION:
Patient was conscious , coherent, cooperative and well oriented to time , place and person .
Thin built and Ill nourished 
History of 10 kgs weight loss 






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





                        


                         



SYSTEMIC EXAMINATION:
CVS -S1 S2 Heard 
CNS - no focal neurologic deficit 
RESPIRATORY - bilateral air entry present 
PER ABDOMEN - tenderness in the left hypogastric region 

VITALS :
TEMP: afebrile 
BP - 110/70 mmhg
PR: 82bpm 
RP: 20cpm 
GRBS : 97 mg/dl 


 INVESTIGATIONS :

UGIE  REPORT : 
 ESOPHAGUS: NO VARICES 
 STOMACH :ERYTHEMA OF THE ARTERIES , PROMINENT GASTRIC FOLDS IN BODY 
IMPRESSION : MILD ANTRAL GASTRITIS

MICROBIOLOGICAL INVESTIGATIONS : 
HIV1/2 rapid test  _ non reactive 
HBsAg rapid - negative 
 
BLOOD SUGAR RANDOM : 97mg/dl 







On :8/6/22



ON 15/7/22








PROVISIONAL DIAGNOSIS : pseudocyst of pancreas

TREATMENT :

  • tab Taxim 200mg 
  • tab PAN 40 mg 
  • INJ tramadol 
  • tab vit c 
  • tab buscopan 
  • tab ultracet







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