Case-1 Epigastric pain and abdominal tightness (28 yr old male)
Sep 06,
Hello, I am Y.N.Indu Vaishnavi,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
A 28 year old male, resident of Narketpalli presented to opd on 1st sep with high grade fever with chills.He again presented with chief complaint of pain in the epigastrium and abdominal tightness on sep 5th.
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 6 days back, then he developed fever at night - 103°F, with chills and rigors but not associated with cough/cold/ headache/nausea/ vomiting/ loose stools/ burning micturition.
He was advised to take dolo 650 and oral fluids and the fever subsided.
Next day evening patient again developed fever(evening rise of temp)with chills but subsided after taking symptomatic medications
Patient now complaints pain in abdomen at epigastrium not subsiding (even with antacids)
Patient also complaints tingling sensation of all 4 limbs since evening not associated with numbness/ postural hypotension/ giddiness/ pain/ weakness
No hematemesis or black tarry stools seen
HISTORY OF PAST ILLNESS
No HTN/diabetes/tuberculosis
He had a right limb fracture 7 years ago and a nail placement was done.
PERSONAL HISTORY
Patient is Unmarried
Farmer by occupation
Bowel movement is regular
Appetite is lost
Micturition abnormal
Non alcoholic
FAMILY HISTORY
No family history of HT/diabetes/ TB/Heart diseases/Cancer/asthma.
PHYSICAL EXAMINATION
A. GENERAL EXAMINATION
Well built
Well nourished
No pallor
No icterus
No cyanosis
No clubbing of fingers
No pedal oedema
No lymphadenopathy
Mild dehydration
B. VITALS
Temperature - 99°F
Pulse -
Respiratory rate -
BP -120/80 on standing
110/80 in supine position
Investigations:
Hemogram-01/09/2022
Serum creatinine-01/09/22
CUE-01/09/22
TPR chart
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