Abdominal Pain and 1 Episode of Emesis since beginning of the day - GM CASE 8
2nd September 2022
CASE STUDY 8
Hello, I am Saloni .S. Gangotri , a 3rd semester medical student. This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.
CASE SHEET:
CHIEF COMPLAINTS:
c/o
- Abdominal pain since morning
- 1 Episode of vomiting
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 3 years back.
But soon developed acute abdominal pain and also vomiting for which he was admitted for 3 days and had been diagnosed Acute Pancreatitis.
After 7 months got treated for the same.
Currently , having the same symptoms.
ASSOCIATED DISEASES:
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PAST HISTORY:
h/o
K/C/O DM since 10-12 years (on some medication for the same )
Is not a K/C/O HTN.
No TB, Epilepsy, CAD.
PERSONAL HISTORY:
Regular Bowel movements.
Has normal micturition with no burning sensation.
Has no known allergies.
Was an occasional alcoholic since 30 years but has stopped consuming since the past 3 years.
FAMILY HISTORY:
Has no history of Diabetes Mellitus, No HTN, No Cardiac Strokes, No cancers.
DRUG HISTORY:
GENERAL EXAMINATION:
-No palor
-No cyanosis
-No lymphadenopathy
-Icterus present
-No edema of feet
-No clubbing of fingers
-Temp - normal
-GRBS - 102
VITALS:
Temperature: febrile
Pulse: 82 beats per minute
Respiratory rate: 16 cycles per minute
Blood pressure: 120/80 mm of Hg
SPO²: 98
SYSTEMIC EXAMINATION:
Cardiovascular system:
No thrills
No murumurs
Cardiac sounds: S1, S2 present
Respiratory system:
No dyspnea
No wheezing
Breath sounds heard: vesicular? yes
Abdomen:
Shape : Scaphoid
No tenderness
No palpable mass
Non palpable liver
Non palpable spleen
No bruits
Bowel sounds: heard
Central Nervous System:
Conscious and Alert
Speech: Normal
INVESTIGATIONS:
Biochemical investigations:
ECG:
2D-ECHO REPORT:
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ULTRASOUND REPORT:
GRAPHIC SHEET:
PROVISIONAL DIAGNOSIS:
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