gm case 3
Hi, I am kashi Supriya of 3rd 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
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?
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