56Y/M with pain in the abdomen

This is an E-log book to discuss our patient's de-identified health data shared after taking his guardian sign informed consent.Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problem with collective current best evidence based inputs.This E-log book also reflect my patient centered online learning portfolio.

Chief complaint:
A 56 year old man came to OPD with the chief complaint of pain in abdomen, abdominal distension and decreased urine output since 4 days.

Patient was apparently asymptomatic 4 days back,then he developed pain in abdomen (upper abdominal region).He complained of distension of abdomen since 4 days.

No history of nausea, vomitings and constipation.last alcohol consumption 5 days back.



History of present illness:



Patient is alcoholic 

Patient has wrist pain since 2 years.

Not a known case of diabetes mellitus, hypertension and CAD.

Personal history:



Diet: mixed 



Appetite:normal 



Bowel movements: normal 



Addictions: alcohol



 Family history:

No similar past family history 



GENERAL EXAMINATION:

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



Vitals
BP - 110/90mmhg
Pressure - 78bp
Temperature-afebrile
Pulse rate - 102
Resp rate - 20 cpm 
GRBS -94
Spo2 - 100% 

SYSTEMIC EXAMINATION
RS-bae+
CVS- S1 , S2+
Investigations:
Treatment:- 
Tab dolo 650 mg TID
Injection neomol IV
Inj pan 40 mg
Monitor bp, spo2 and temperature 
Inj vit B12 1500ml mg in 100ml NS over 1hr.

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