Abdominal pain

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed 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 patients clinical problems with collective current based inputs.




A 56 year old male ,  came to casualty with the c/c of pain in abdomen  and abdominal distension,Decreased urine output  since 4 days

History of present illness

Patient was apparently asymptomatic 4 days back then he developed pain in upper abdominal region.
History of distension of abdomen since 4 days.
No history of nausea, vomiting, constipation.

History of past Illness 
N/k/c/o  DM, CVA,CAD,TB,Asthma, Hypertension

Personal history
Marital status: married
Occupation : Farmer
Appetite : Normal
Bowels: Regular
Micturition : Abnormal since 4 days
Allergies:No
Diet: nonvegetarian
Habits: Alcoholic (Regular)

Family history

No significant family history. 


General Examination


Patient was conscious, coherent and cooperative 

No icterus,pallor,cyanosis lymphadenopathy,clubbing of fingers & toes
Vitals:
Temp - afebrile 
Pr :102bpm
Rr 20cycles/min
BP 120/90 mmhg 
Spo2 98% at room air 
Grbs 94mg%



Systemic Examination 


CVS - s1 s2 + ,No murmurs 
RS - No dyspnea, vomiting, vesicualr breath sounds
Position of trachea : central
Abdomen- Distended, no palpable mass
Liver not palpable
Spleen : not palpable
Bowel sounds :Yes

CNS - 
Conscious
Speech- normal
Neck stiffness- No
Kerning's sign- No
Cranial nerves-normal
Motorsystem-normal
Sensory system-normal
Glasgow scale- normal

Investigations
Usg abdomen
ECG
Complete blood picture

Provisional diagnosis- pain in abdomen 


Treatment
TAB. Dolo 650 mg BID
Injection. Neomol1 gm
Injection. Pan 40 mg
Injection vitamin b12 1500 mg in 100 ml NS over 1 hr






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