28 year old patient with epigastric pain

 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

28 year old male resident of Manimidhe presented to opd with epigastric pain


CHIEF COMPLAINTS

Epigastric pain since 7 days which is associated with cough
Swelling in the right lower abdomen with puss discharge since 7 days

HISTORY OF PRESENT ILLNESS 
Patient is apparently asymptomatic 7 days ago
Then he had epigastric pain on the right side which is incidents on onset, gradually progressive which aggravates on leaning forward, sitting and coughing
It regressed on lying down 
Not relieved on medication
2 days back he had fever with no chills that subsided on medication.
No nausea

HISTORY OF PAST ILLNESS 
No HTN/diabetes

PERSONAL HISTORY
Patient is a farmer by occupation 
married
Bowel movement is regular
Burning Micturition
alcoholic

FAMILY HISTORY 
No significant family history 

PHYSICAL EXAMINATION 

A. GENERAL EXAMINATION

Well built
Well nourished
No pallor
No icterus
No cyanosis
No pedal oedema
No clubbing of fingers
No lymphadenopathy
Mild dehydration

B. VITALS

Temperature - Febrile
Pulse - 92 bpm
Respiratory rate - 17
BP - 110/80
GRBS - 88 mg%

SYSTEMIC EXAMINATION

 A. CVS
- No thrills
- S1 S2 positive
-no cardiac murmurs

B. RESPIRATORY SYSTEM 
- no dyspnoea 
- No wheezing
- central trachea
- vehicular breath sounds 

C. ABDOMEN
- palpable liver
- Bowel sounds

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