Hi, I am Yeddula Vishnu Priya, 3rd semester medical student. This is our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. This elog also reflects my patient centered online learning portfolio
A 28 year old male resident of Manimidhe presented to opd with epigastric pain
CHIEF COMPLAINTS
Epigastric pain since 7 days which is associated with cough
Swelling in the right lower abdomen with puss discharge since 7 days
HISTORY OF PRESENT ILLNESS
Patient is apparently asymptomatic 7 days ago
Then he had epigastric pain on the right side which is incidents on onset, gradually progressive which aggravates on leaning forward, sitting and coughing
It regressed on lying down
Not relieved on medication
2 days back he had fever with no chills that subsided on medication.
No nausea
HISTORY OF PAST ILLNESS
No HTN/diabetes
PERSONAL HISTORY
Patient is a farmer by occupation
married
Bowel movement is regular
Burning Micturition
alcoholic
FAMILY HISTORY
No significant family history
PHYSICAL EXAMINATION
A. GENERAL EXAMINATION
Well built
Well nourished
No pallor
No icterus
No cyanosis
No pedal oedema
No clubbing of fingers
No lymphadenopathy
Mild dehydration
B. VITALS
Temperature - Febrile
Pulse - 92 bpm
Respiratory rate - 17
BP - 110/80
GRBS - 88 mg%
SYSTEMIC EXAMINATION
A. CVS
- No thrills
- S1 S2 positive
-no cardiac murmurs
B. RESPIRATORY SYSTEM
- no dyspnoea
- No wheezing
- central trachea
- vehicular breath sounds
C. ABDOMEN
- palpable liver
- Bowel sounds
C. CNS
- conscious and coherent
- normal speech
INVESTIGATIONS
HEMOGRAM
- Hb - 14.9
- TLC - 13,000
- RBC - 14.82
- PLT - 3.2
USG
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