Welcome and greetings to every one who are visiting my blog. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.
HISTORY OF PRESENT ILLNESS:
Pateint was apparently asymptomatic till morning when suddenly he developed pain in the upper abdomen which was non radiating and also had 6-7episodes of vomitings -which had water as the content and non projectile in nature.
HISTORY OF PAST ILLNESS:
Patient is not a known case of diabetes, hypertension, epilepsy,asthama, tuberculosis.
No history of surgery
PERSONAL HISTORY:Married and has a child
Appetite:normal
Diet:mixed
Sleep:adequate
Bowel and bladder movements:normal
Addictions: alcoholic (90ml every day since 15years)
No known drug history
GENERAL EXAMINATION:
Patient was concious, cooperative, coherent and well oriented to time place and person.
No pallor,cyanosis,clubbing, lymphadenopathy,edema of feet.
Vitals:
Temperature:98.4C
Pulse rate:90
Respiratory rate:16
SpO2:90
Blood pressure:110/80mm/Hg.
CVS :
S1&S2heard,no thrills,no murmor.
RESPIRATORY:
Vesicular breath,trachea in central position,no wheeze,no dyspnea.
ABDOMEN:
Scaphoid,mild tenderness in epigastric region,no palpable masses,. Nnormal hernial orifices,no bruit
Spleen,liver non palpable
CNS:
Concious
Speech:normal
Gait:normal
No neck stiffness
Sensory,motor systems are normal.
INVESTIGATIONS:
Hemaglobin:13.8gm/dl ;Tlc:7400;RBC:4.25
MCV:96;MCH:32.5;MCHC:338;PLT:1.57;PCV:40.8
Lipase:29,amylase:84;RBS:144;urea:20, creatinine:0.9, sodium:137, potassium:4, chloride:102
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