Case 9

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

A 80 year old male is presented to OPD with chief complaints of stomach pain and no urination since 10 days.

HISTORY OF PRESENT ILLNESS 

Daily routine(before illness)

He used to wake up by 5am and was done with his breakfast by 7am then he used to go to the field and then return back home by 6pm and had his dinner by 8pm and then sleep at night by 9pm.

Daily routine(after illness)

He used to wake up anytime and then he used to feed cattle near his home and he didn't used to do much work at home.

Patient was apparently alright 6 months back then he developed stomach pain and constipation as well and went to nearest hospital and was on medication.

Pain subsided after medication but somtimes he used to have stomach pain after eating any citrus fruits or vegetables.

He even had constipation sometimes but on medication it was subsided.

HISTORY OF PAST ILLNESS

Patient has no history of diabetes, asthma, hypertension , tuberculosis.

Patient was not underwent any surgery before.

FAMILY HISTORY:

No revelent family history.

PERSONAL HISTORY:

Diet: mixed

Appitite: decreased. 

Constipation : since 8 days.

Bowel bladder movement: normal.

Addictions : patient has habit drinking alcohol regularly and smoking regularly .

GENERAL PHYSICAL EXAMINATION:

Patient concern was taken and examined in well lit room.

No pallor, cyanosis, icterus , clubbing and lymphadenopathy. 

Patient has no pedal oedema, bleeding gums, rashes and haematasis.

VITAL SIGNS:

Temperature : aferible

Pulse rate : 94beats /minutes.

BP: 130/ 90 mmHg.

Respiratory rate:18/minutes.

SpO2:98%

SYSTEMIC EXAMINATIONS

Cardiovascular system:

No thrills and cardiac mummurs .

S1 and S2 are heard .

Respiratory system:

No wheezing and dyspnoea.

Positioning of trachea is central and breath sounds are vesicular.

Abdomen:

Abdominal distinction not seen.

No tenderness and no palpable mass is present.Hernial orfices are normal.

No free fluid and bruits and liver and spleen are not palpable .

bowel sounds are not heard .

Central nervous system:

Patient is conscious and speech is normal.No signs of meningeal irritation such as neck stiffness and kerning's sign.

Cerebral signs such as finger - nose in coordination and knee - heal incoordination are not present .

INVESTIGATIONS: