OPD-1) 45 years old male patient came with c/o constipation , loss of appetite since 10 days and hiccups since 3 days
Hi, I am Y.Varunkarthik , 5th semester medical student.
This is an online E-log book 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 patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs 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.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.
Chief Complaint
45 years old male patient came with c/o constipation , loss of appetite since 10 days and hiccups since 3 days
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 10 days ago then later he developed constipation , loss of appetite and hiccups when he meet with road traffic accident 10 days back.
Patient passed only 3-4 stools in a duration of 10 days due to stoppage of food intake and has no complaints of pain and discomfort during defecation,not associated with blood and no abdominal pain
Patient also complaints of loss of appetite since 10 days with no associated symptoms like weight loss, vomiting,chest pain.
He mainly complaints of hiccups since 3 days intermittently(appears and disappears randomly according to patient words),no aggrevating and relieving factors and no associated symptoms like cough,weight loss and abdominal pain.
NEGATIVE HISTORY:
No h/o headache ,fatigue, giddiness
No h/o chest pain,sob,cough,cold
No h/o orthopnea,sweating,palpitation
No h/o burning micturition
No h/o nausea,vomiting
HISTORY OF PAST ILLNESS:
Patient met with accident 10 days
K/c/o hypertension since 3 months and is on TELMISARTAN 40mg.
N/k/c/o diabetes mellitus/epilepsy/asthma/TB/thyroid disorders
No h/o blood transfusion
FAMILY HISTORY:
Patients mother is a known case of hypertension
GENERAL EXAMINATION:
The patient is conscious,coherent and NOT cooperative.
ALL INFORMATION WAS GIVEN BY ATTENDANT WHO WAS RELIABLE.
No pallor,icterus,cyanosis, clubbing of fingers, lymphadenopathy and pedal edema.
VITALS:
Temperature:- afebrile
PR:- 80/min
Bp:-130/90 mmhg
RR:- 22 cps
Systemic examination
CVS:
No thrills
S1,S2 are heard
No murmurs
Respiratory examination:
- No Dyspnoea
- No wheezing
- central trachea
- Normal vesicular breath sounds
- BAE+
ABDOMEN
- abdomen - obese
- No tenderness
- No palpable mass
- non palpable liver and spleen
CNS
- conscious and coherent
- normal speech
Treatment
Tab.ondron.md po/sos
Syrup.cremaffin po /od.
