Case history-9

 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.

A 70 year old male brought to casuality with c/o constipation since 20 days (on and off)

Not passing stools and Flatus since 5 days

Shortness of breath since 5 days

History of present illness:

Patient was apparently asymptomatic 3 years back and then he developed pain abdomen in epigastrium localized and not a/w nausea or vomitings aggravated after food intake

Since 1 year patient complains that he used to wake up in the middle of night and felt breathless for a while. Since 20 days patient complains of generalised weakness with loss of appetite and has constipation with small quantity of hard stools. Since 5 days patient complains he didn't pass stools and flatus which makes him discomfort associated with pain abdomen

Personal history

Patient lost his appetite since 20 days and disturbed sleep

Addictions: H/o Smoking  (Sutta) since 55 years. chronic alcoholic drinks 90ml whiskey dail

General examination:

Patient consious, coherent, cooperative

No pallor, icterus, clubbing, lymphadenopathy, edema

Vitals

Temp: afebrile

Pr: 90 bp

Rr: 20 cp

Bp: 130/80 mmh

Spo2: 98

Grbs- 132 mg/d

Systematic examination

CVS: S1 and S2 hear

RS: BAE +

P/A: soft , tender

CNS: NA

Investigation:

Hemogram

Hb- 11.

Tlc- 29,30

Plt count- 1.6

RF

Urea- 20

Creatinine- 5.

Na+- 13

K+- 4.5

Cl-- 9

LF

ALP- 43

ALB- 2.

CU

ALB 

RBC - Absent

AB

Ph- 7.47

Pco2- 23.

So2- 95.

cHCO3 (P.ST)c- 20.

cHCO3(p)c- 17.

Serology- negative.38693G:.+E:87T:0 792T:205:s:D. d:l%0mme: a.n:.s:D. d:l%gmme: ae.on:y..y:..s:. .

Diagnosis: constipation to? Uremic gastroparesis with RCA territory akinesia (?old MI)