Saturday, July 22, 2023

A 65 year old male with PAIN DISTENDED ABDOMEN and PAIN IN RT CHEST since 1 yr

65 year old male from beemanapally

Introduction: Welcome to my blog! I am U.AKANKSHA a 4th year medical student.This is an online E-log Entry Blog to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs.It also reflects patient centered online learning portfolio.

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.

Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references. 

Date of admission 21/7/23

65 yr old male agricultural labourer by occupation came to OPD with C/O abdominal pain, lower back pain radiating to b/l lower limbs, neck pain with stiffness since 1 year. 

History of present illness:

Patient was apparently asymptomatic 1 year ago later he developed pain in abdomen which
Insidious in onset gradually progressive. It is diffuse and dull causing discomfort.It is aggravated on eating,performing daily activities and walking.

Pain in the chest is lasts for 2-5 min which is sudden in onset.It is relieved by massaging that particular area.

Yesterday night patient complained of pricking type of headache due to dental carries on the right lower molars due to which he was unable to sleep. 

Past illness:
Diabetes since 15 years.
Not a K/C/O  HTN, TB, asthma, epilepsy or any other chronic illness.
TRAUMA :
4 years back, then he had a fall while taking his cattle to the field due to which the patient experienced severe pain in the right hip and was unable to walk. 
Right hemiarthroplasty was done immediately. 
Since 1 yr the patient gradually developed backache and dragging type of pain in b/l lower limbs.
 He had difficulty in bending, difficulty in getting up from sitting position, joint stiffness+.

Drug history 
Insulin injections twice daily

Personal history 
Diet mixed 
Sleep is adequate 
Appetite decreased
Bowel and Bladder: normal
No Allergies 
Addiction: alcohol occasionally once in few weeks

Daily routine
The patient wakes up at 5 am and gets ready.
He generally prefers to have roti and curries for his breakfast.

After that he sleeps for few hours.
His lunch items includes rice and vegetables, mostly around 1pm.
Then he goes outside for a walk in the evening and is back by 8pm for dinner.

Patient is an agricultural labourer but has left his job since he was diagnosed with diabetes that is 15 years back.

General examination

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

No pallor, icterus, cynosis, clubbing,edema, lymphedenopathy 

Vitals

Pulse rate-68 bpm
Blood pressure- 130/80mm Hg
Respiratory rate- 16cpm
CVS- S1S2 +, no murmurs
RS- BLAE +, NVBS heard














Investigations

Ultrasound 


ECG


2D ECHO




TREATMENT:-

Biphasic insulin 
Pantoprazole 40mg
Multivitamin tablets


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