35 year old male with pain abdomen and vomitings
This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.
Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
This E-blog also reflects my patient's centred online learning portfolio.
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 a diagnosis and treatment plan.
M.Abhignya 8th sem
03/06/21
Case
35 year male pt came to the OPD on 02/06/21 with the chief complaints of :
Pain in upper abdomen since 1 day
vomitings since 1 day
History of present illness
Pt. was apparently asymptomatic 1 day back and then developed persistent
*Pain in upper abdomen which was sudden in onset ,gradually progressive in
nature and it was Throbbing and Sqeezing type
- pain is localized to EPIGASTRIC and LEFT HYPOCHONDRIAC regions
and Radiating to Left side of upper back
-Pain is associated with Vomitings-since 1day
2 episodes after the intake of toddy 1 day back,vomitings were non-bilious, non-projectile and food as the content
*vomitings subsided after treatment from local RMP , but due to persistent pain Pt. came to our hospital for futher management
-No H/O fever / loose stools/ constipation
-No H/O outside food consumption
-No H/O burning micturation
-No H/O trauma
Past history
##H/O similar episode 6 months back , it was relieved after taking treatment from RMP
Not a K/C/O --HTN , T2DM , TB , Asthma , Epilepsy , CAD ,
k/c/o Chronic plaque psoriasis since 18yrs of age
- Itchy lesions over both lower limbs - they are multiple , well defined , scaly , hyperpigmented
-h/o exacerbation during winters and on intake of alcolol
-h/o topical medication usage on & off
No H/O previous surgeries
Personal history
Diet - mixed
Appetite - decreased
Bowel and bladder movements - regular
No allergies
Addictions--chronic alcoholic since 3yrs (90-180ml/day)
Family history - not significant
General Examination
The patient is examined with informed consent.
Patient is consious, coherent, cooperative,is well oriented to time,place,person.
He is Moderately Built and nourished.
Pallor : absent
Icterus : absent
Cyanosis : absent
Clubbing : absent
Lymphadenopathy : absent
Edema : absent
VITALS
Temperature: Afebrile
Pulse Rate: 110 beats per minute
Blood pressure: 150/110 mm of Hg
Respiratory Rate: 12 cycles per minute
SpO2: 98% on room air
GRBS-147mg/dl
Systemic Examination
on 02.06.21
CVS - S1 and S2 heard No added thrills,murmurs
RESPIRATORY SYSTEM - BAE (+) - vesicular breath sounds - position of trachea -central - no dyspnoea and wheeze
PER ABDOMEN : shape - scaphoid Tenderness - present in Epigastric & Left hypochondrium No palpable mass Guarding and rigidity : ABSENT Hernial orifices are Normal No free fluid and bruits Liver & Spleen are not palpable Bowel sounds (+) Genitals - Normal
CNS - HMF intact conscious ,oriented to time ,place and person Glasgow scale -15/15
Investigations
Haemogram
CUE
RFT
LFT
ECG
CXR
Serum Amylase
Serum Lipase
ULTRASOUND REPORT
Impression
*Mild free fluid noted in Perihepatic ,B/L paracolic gutter and pelvic region
*Hyperechoic and enlargedancreas
*Grade 1 fatty liver
CT
Provisional Diagnosis
Acute Pancreatitis
Treatment
on 02.06.21
NBM
IVF -NS , RL , DNS @ 25Oml/hr
INJ. PANTOP 40 mg IV , OD
INJ. THIAMINE 100 mg in 100 ml NS IV , TID
INJ. TRAMADOL in 100 ml NS IV , BD
INJ. ZOFER 4mg IV/SOS
Tab. PARACETAMOL 500mg PO/SOS
Minitor vitals -4th hourly
Temperature charting
Comments
Post a Comment