GENERAL MEDICINE

GENERAL MEDICINE

March 3rd, 2023
GM- CASE 4

Friday, March 3rd 2023

3rd March 2023
CASE scenario....

Hi, I am G Sukanya 3rd year bds student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolio.
 
Case History 
A 48 years old male Resident of kurumarthi,work as daily labour presented with the 
Chief Complaint of
Abdominal pain and Constipation along with abdominal distension/Swelling since one month 
History of present  illness 
Patient was apparently asymptomatic 1 month back but suddenly had severe Abdominal pain with Abdominal distension/Swelling due to bloating òf gas and constipation  without bowel movement even a single day. Abdominal pain is dull aching type that radiated to backwards and this pain is aggrievated by eating food and relieved on medication...and the patient was unable to lift the weight as that he does in labour work. so,he came to hospital for treatment due to severe Abdominal pain .After using medication here, he passed the stools with flatus. 
History of past  illness 
From past 2 years patient was suffering with Irregular Bowel movement/constipation rarely  with abdominal pain in some situations 
Blood in stools 6 months back and relieved on medication....
Blood transfusion was done 4 days back
No vomiting
No Tuberculosis 
No Asthma 
Not having Daibetes 
No Hypertension 
Family history 
No one in the family have Daibetes or Hypertension or any other problem
Personal history 
Married 
Diet:mixed but stopped 3 years back 
Apetite:present but he was unable to eat food because of  abdominal pain ,and he was on fluid now...
Bowel:Irregular Bowel movement 
Micturition:Regular
Sleeping:now it's good but before there was inconvenience in sleeping due to abdominal pain 
Habits:Alcohol consumption from 20 years but stopped 2 years back 
 Tobacoo Chewing from 20 years but stopped 3 months back.
General examination 
Built:Normal Built 
Nourishment: Good 
Consciousness:in Conscious 
Pallor:No
Icterus:No
Cyanosis:No
Lymphadenopathy:No
Oedema :No Edema 
But there is only one feature mainly seen was
Abdominal distension/Swelling 
Drug history 
Vitals 
Pulse rate:78bpm
Blood pressure:120/80
Spo2:99%
Report 
Patient had severe abdominal pain near the umbilicus that is radiating backwards.... and had Abdominal distension/Swelling due to some obstruction in the intestine.As per my assumption abdominal Swelling was due to obstruction by intestinal feces as the patient had constipation from several days  
            
               PROVISIONAL DIAGNOSIS

                   Intestinal obstruction 
     
Q/A
1)Is there any re occurance of intestinal obstruction ?
2) How to get rid of the Constipation permanently?
3)Do I  need any surgery for the abdominal distension?

 

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