56 year old patient with pain in abdomen

 This is an E-log book to discuss  our patient's de-identified health data shared after taking his guardian sign informed consent.Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problem with collective current best evidence based inputs.This E-log book also reflect my patient  centered online learning portfolio.


A 56 year old male came to OPD with the chief complaint of pain in abdomen, abdominal distension and decreased urine output since 4 days.

Patient was apparently asymptomatic 4 days back,then he developed pain in abdomen (upper abdominal region).He complained of distension of abdomen since 4 days.

No history of nausea, vomitings and constipation.last alcohol consumption 5 days back.


HISTORY of Past Illness 


Patient is alcoholic 

Patient has wrist pain since 2 years.

Not a known case of diabetes mellitus, hypertension and CAD.


PERSONAL HISTORY


Diet: mixed 


Appetite:normal 


Bowel movements: normal 


Addictions: alcohol


GENERAL EXAMINATION

Patient is conscious, coherent, cooperative, well oriented to time, place and person.


VITALS 


BP - 110/90mmhg


Pressure - 78bpm


Temperature-afebrile 


Pulse rate - 102


Resp rate - 20 cpm 


GRBS -94


Spo2 - 100% 


SYSTEMIC EXAMINATION


RS-bae+

CVS- S1 , S2+















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