A 65 yr old male with abdominal pain

 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.


Patient came to OPD with chief complaints of pain abdomen since 4 days

HOPI :  
Patient was apparently asymptomatic 4 days back then he developed pain in the abdomen, insidious in onset, gradually progressive dragging type,aggravated on doing work ,after sudden increament in the consumption of alcohol (90ml to 180ml)not associated with nausea,vomitings
No h/o constipation 
H/o burning micturition

Past history 
N/k/c/o HTN, Asthma, epilepsy,TB , CAD,CVA
No h/o surgeries in the past 
No H/O blood transfusion 
No h/o radiation exposure

Personal history: patient is farmer by occupation 
Diet mixed
Appetite decreased since 4 days 
Sleep adequate
Bowel and bladder regular  
Burning micturition
Addictions regularly consumes alcohol about 90 ml/2day Since 30 years 

Daily routine:-
Patient  wakes up at 6:00am approx. and goes for walk for 1hour and freshen ups and have a cup of tea and goes for farming then he will have his lunch at 2:00 and then comes back home around 5:00 and have tea and have dinner at around 8:00 and goes to bed at 9:00 
Alcohol comsumption every alternate days

General physical examination
Pt is conscious coherent cooperative well oriented to time place person
Moderately built and nourished
Vitals
BP : 130/80 mm Hg 
PR :  69 bpm
Spo2 98 on RA 
Temp:  98.3 F
GRBS 197 mg/dl
No pallor, cyanosis, clubbing,
lymphadenopathy,edema
Icterus present 

Systemic examination : 
Cvs- s1 ,s2 heard
CNS- no focal neurological deficits noted
Rs -BAE + , NVBS 

P/A 
Inspection : abdomen flat 
No scars,sinuses,hernial orifices, pulses,masses,
All quadrants are moving equally with respiration
On palpation: 
All inspectory findings are confirmed 
Abdomen soft 
Tenderness in epigastric and both hypochondriac regions
No local rise of temperature
On percussion:
No fluid thrills  no shifting dullness 
Tympanic note heard
On auscultation :
Bowel sounds heard
Investigation:-


CBP:-


Serum lipase:-



LFT 



AMYLASE 


 
RBS


USG abdomen and pelvis





Chest X ray




X ray abdomen

Provisional diagnosis : acute on chronic pancreatitis

Treatment:-
Inj ceftriaxone 2 g /IV / BD 

INJ METROGYL 500 mg IV /TID

Inj thiamine 200 mg in 100 ML NS IV/tid 

Inj Tramadol 100 mg in 100 ML NS IV/BD 

INJ PAN 40 Mg IV /OD 

INJ ZOFER 4 Mg IV /BD

Comments

Post a Comment

Popular posts from this blog

Image
 Diagnosis DIMORPHIC ANAEMIA(BICYTOPENIA) WITH CKD(STAGE 4) WITH 4 SESSIONS OF HEMODIALYSIS DONE(2019) Case History and Clinical Findings COMPLAINTS: 80 YEAR MALE WITH C/O TINGLING AND NUMBNESS OF BOTH UL AND LL SINCE 1 WEEK. HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC TILL LAST WEEK,THEN DEVELOPED HAEMATURIA SINCE LAST FRIDAY, IN EACH EPISODE OF URINE OUTPUT, WHICH LASTED FOR 4 DAYS.NO AGGREVATING FACTORS, NO RELIEVING FACTORS. H/O DECREASED URINE OUTPUT SINCE 1 MONTH, BUT INCREASED FREQUENCY. NO H/O BURNING MICTURITION, HESITANCY OR URGENCY NO H/O BLEEDING MANIFESTATIONS,PETECHIAE,RASH,NO HEMATURIA,NO BLOOD IN STOOL(MELENA),NO BLLEDING GUMS. NO H/O FEVER, COUGH, COLD, PAIN ABDOMEN NO H/O CHEST PAIN, PALPITATIONS, ORTHOPNEA AND PND TINGLING AND NUMBNESS OF UL AND LL SINCE 1 WEEK. NO POLYPHAGIA,POLYDYPSIA,NOCTURIA POLYURIA PRESENT UROLOGY REFERRAL TAKEN IN VIEW OF HEMATURIA ?URINARY BLADDER CARCINOMA DIAGNOSIS:BPH WITH GRADE 2 RPD CHANGES ADVICE:T.TAMSULOSIN 0.4 MGX2 WEEKS T.PANTOP 40MG
Read more

A 21 yr old female with pyrexia and vomitings

Image
  July 26, 2022 Medical case disscussion  July 23,2022 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 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 inthe comment box are welcome. Name : Jyothi Reddy  Roll no : 44 I have been given this case to solve an attempt to understand the topic of "patient clinical analysis data " to develop my competency in reading and comprehending clinical data including clinical history,clinical findings, investigations and come up with a diagnosis and treatment plan          CASE DISCUSSION A 21 year old female patient from Islamilpalli , who's a Bsc nursing st
Read more

GM CASE DISCUSSION

  MEDICINE CASE DISCUSSION This is 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 patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome August 03, 2021 A 15YR BOY WITH COMPLAINTS OF FEVER  A 15year old male patient resident of Narketpalli came to the opd with the chief complaints of  -fever since 4 days History of presenting Illness- Patient was apparently asymptomatic since 4 days back when he developed fever  which was sudden in onset,intermittent,low grade, associated with chills and was relieved on  medication. -No H/O vomitings  -No H/O cold,cough,headache,sob -No H/O rash,pain abdomen ,l
Read more