GENERAL MEDICINE - 18

 70 YEAR OLD MALE CAME WITH THE CHIEF COMPLAINTS OF  VOMITING AND GIDDINESS  AND PAIN ABDOMEN SINCE YESTERDAY 

This is an online E log book by D.SRI SNEHITHA 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 series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. I've 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 a diagnosis and treatment plan. 

CHIEF COMPLAINTS:

A  70 year old male  came with the chief complaints of: 

Vomiting , giddiness, pain abdomen since yesterday

HISTORY OF PRESENT ILLNESS: 

The patient was apparently asymptomatic 2 days back. He then complained of vomiting which has rice and water , 

Non blood stained and suddenly fell unconscious

Then he complains of pain abdomen which is  sudden in onset, aching type  , intermittent and non radiating

He also complained of  generalized weakness and body pains 

No aggrevating and relieving factors.

No history of ,diarrhea, constipation

PAST HISTORY:

  Previous history of diabeties  3 years back and on regular medication with metformin 

Not a known case of asthma ,hypertension, tuberculosis, epilepsy, coronary artery disease, cerebrovascular accidents.

No similar complaints in the past

No previous surgical history

PERSONAL HISTORY:

Diet: Mixed

Bowel : regular

Micturition: normal

Appetite: decreased

Habits:alcoholic (90 ml per day) 

Sleep: inadequate 

No history of allergy.

Family history:

Insignificant

Drug history:  metformin since 3 years

GENERAL EXAMINATION: 

The patient is examined in a week lit and well ventilated room

Moderately built and moderately nourished

pallor present

icterus present

No cyanosis

No clubbing

No lymphadenopathy

VITALS:

Temperature: febrile

Pulse: 78 beats per minute, irregular

Respiratory rate: 18 cycles per minute

Blood pressure: 120/80 mm of Hg