57 year old male with abdominal pain
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I have 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 diagnosis and treatment plan.
AFEEFA FARZANA ,8th SEMESTER
Roll no:09
This is a case of 57 year old male , resident of nalgonda district ,daily wage labourer
CHIEF COMPLAINTS:
Abdominal pain since 9 days
SEQUENCE OF EVENTS:
Patient was apparently asymptomatic 9 days ago then he developed fever which lasted for one day on 25 June 2022 associated with chills and rigors and subsided with medication and
on that day evening he developed epigastric pain which was radiating to both the flanks,sudden in onset,gradually progressive stabbing type of pain ,pain aggravated on eating food
He also complained of shortness of breath grade 3 on the same day which was relieved
No history of nausea and vomiting,diarrhoea
DAILY ROUTINE:
He wakes up at 4:00am and completes his daily activities.He goes to work at 5:00am and does watering in the field and come back home at 8:00 am have breakfast and goes back to work ,he does different work daily ,depending on the work he gets that day and come back home in the evening by 7:00 pm. He consumes alcohol daily before eating dinner and then eats food and sleep
EVENTS LEADING TO THE PRESENT DAY:
The patient as usual woke up and went to work. He said his work that day was spraying fruits with some chemicals. He came home around at 11 am that day to have food. He had rice and dahl and developed fever insidiously after eating. His fever subsided in the evening and then he developed epigastric pain. He has not been going to work since the past few days and is at home taking rest since the pain is so severe. No one else in the family had similar complaints.
PAST HISTORY:
No similar complaints the past
Not a known case of Hypertension, diabetes
PERSONAL HISTORY :
Diet :mixed
Appetite : decreased
Bowel and bladder :regular
Sleep: adequate
Addictions: smoking beedi since 40 years .He smokes. 25 beedis per day
Alcohol consumption since 30 years daily 90 ml before having dinner
GENERAL EXAMINATION:
Pallor: present
Icterus : absent
Cyanosis: absent
Clubbing:absent
Lymphadenopathy:absent
VITALS
Temp :afebrile
BP:120/80 mmHg
Heart rate :90bpm
Resp rate :18cpm
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