male pateint with lower abdominal and lower back pain(case 1)

28th July 2022

General medicine blog

 I Ebrahim Badshah a 3rd semester student . This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolio.

The patient’s consent was taken prior to history taking and examination of his condition.

I've 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 a diagnosis and treatment plan. 

CHIEF COMPLAINT

 A 43 years old male patient, from West Bengal, driver by occupation,came to the hospital with chief complaints of lower abdominal pain and lower back pain.

complaint of gas in gastric region.

HISTORY OF PRESENT ILLNESS

He isnt able to sleep properly since the last 8 months due to pain.

Patient also has severe gastritis problem since last 20 years which he suffers in episodes and is cured when he takes medicines.

According to him, his gastritis problem are

because of his occupation ,he has improper eating habits and irregular food timings .

PAST HISTORY : 

No DM, 

No HTN, 

No TB, 

No Epilepsy , 

No Asthma. 

PERSONAL HISTORY :

The patient is a chronic cigarette smoker and drinks alcohol occasionally 

Mixed diet , spicy intake food

Inadequate sleep

Irregular bowel movements , constipation occurs

PHYSICAL EXAMINATION:

Patient is conscious and coherent

No pallor

No icterus

No clubbing 

No pedal oedema 

No lymphadenopathy 

Malnourished/thin 

No cyanosis

VITALS:

Temperature:Afebrile 

BP:100/70 mm Hg

HR:80/min

RR:18/min

FAMILY HISTORY:

 Mother has high blood pressure since 2 years

ALLERGY HISTORY:

None