E LOG GENERAL MEDICINE
August 23, 2023
Hi, I am Mohd Shoeb ul haque , 5th Sem Medical Student.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 patient's clinical problems with collective current best evidence based inputs.
This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.”
I've 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 a diagnosis and treatment plan.
A 54 year old male with complaints of abdominal pain since 2-3 months with associated belching.
Shortness of breath Grade 2
History of present illness-
A patient was apparently asymptomatic 3 months ago then he developed abdominal bloating, which aggrevated after food intake, which relieves after taking PPI
Belching positive
No regurgitation
History of shortness of breath grade 2 which aggrevated since 3 month after belching of abdomen
No history of chest pain palpitations, decreased urine output, facial puffiness
H/O trauma to left 8th rib while doing regular labour work, and continuous left side chest pain, dragging type, aggrevates on movement and deep inspiration
Past illness-
No relevant past history
Personal History-
Diet: mixed
Appetite: normal
Sleep: adequate
Bowel: regular
Bladder: normal urination
Addictions: alcoholic
Family History-
No significant family history
General Examination:
Patient was conscious coherent and cooperative
No pallor, Icterus , Clubbing, Cyanosis, Generalised lymphadenopathy
Vitals-
Temperature: afebrile
Pulse: 72bpm
Breath rate: 15/min
Bp: 120/80
Provisional Diagnosis-
Acid peptide disease, 8th rib fracture
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