2nd Internal assessment PRACTICAL GM 5/12/22

- December 04, 2022

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 diagnosis and treatment plan.

38 yr male with abdominal pain

CHIEF COMPLAINTS

38 yr old male came to Gm opd with chief complaint of abdominal pain since 5 years

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 5 years ago then he developed pain in upper abdomen which is insidious in onset and gradually progressive,dragging type of pain radiating to back of thorax. Initially the pain used to be once in every 6 months but from 6 months the pain occurs once or twice in every month associated with vomiting

Aggravated on taking heavy food and alcohol and relieved temporarily on medication

On 13th November he had 130 episodes of vomiting after having food or water. Initially vomitus contain undigested food partials later it contain thick Yellow color fluid. Vomiting was associated with weakness. He was treated temporarily in local hospital.

On 23rd he had another episode of pain..temporarily he got treated in local hospital and on 27th he was admitted in our hospital.