55 year old male with acute dysentery,? Acute on chronic pancreatitis secondary to Cholelithiasis
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E.Laharika
Roll no: 29
- 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.
CASE PRESENTATION:
55 year old male, farmer by occupation presented with chief complaints of:
- Loose stools since 5 days
- Pain abdomen
- Fever
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 5 days back then he had loose stools (greenish coloured)- 6 to 8 episodes/day in small volume,watery in consistency.
He also complained of pain in the abdomen on consuming food which is colicky type,intermittent,not radiating.
From past 2 days, he's experiencing frank blood while passing stools ( 1-2 episodes/day) along with watery stools.
He had Fever for 1 day which is low grade , intermittent in onset and subsided on medication.
H/O weight loss present
H/O outside food consumption 5 days ago
No h/o piles
No h/o cough , cold, SOB
No history of nausea / vomiting
No h/o Burning micturition/Hemoptysis/Melena.
PAST HISTORY:
Patient is not a known case of Diabetes mellitus/hypertension/TB/Asthma/Epilepsy
No history of any previous surgeries
PERSONAL HISTORY:
Diet-mixed
Appetite-decreased
Sleep-decreased
Bowel and bladder movements- loose motions (now stable)
Occasional alcoholic
Family history:
Not significant
GENERAL EXAMINATION
Patient is conscious, coherent and cooperative,well oriented to time, place and person.
He's moderately built and Nourished.
No pallor
No icterus
No Cyanosis
No clubbing
No lymphadenopathy
No edema
VITALS:
Temperature-Afebrile
BP- 130/70 mm hg
PR -78 bpm
RR- 17 cpm
Spo2 99% at RA
SYSTEMIC EXAMINATION:
CVS- S1 S2 sounds are heard
RS- Bilateral air entry decreased
PER ABDOMEN EXAMINATION:
Soft and mild tenderness is present in the hypogastric region.
Bowel sounds are heard.
No palpable mass or free fluid
CNS - speech is normal
Reflexes are normal
Motor and sensory system-normal
Cranial nerves-intact
No meningeal signs
INVESTIGATIONS:
CBP
CUE
Sugar ++++
Blood urea
LFT
SERUM CREATININE
SERUM ELECTROLYTES
SERUM AMYLASE
RANDOM BLOOD SUGAR
GLYCATED HAEMOGLOBIN
X rays
Ultrasound report
Impression:
Diffusely altered echotexture of pancreas
Cholelithiasis
Grade 1 fatty liver
Raised echogenicity of both the kidneys
Few tiny renal calculi in left kidney.
ECG:
PROVISIONAL DIAGNOSIS:
Acute dysentery
? Acute on chronic pancreatitis secondary to Cholelithiasis
TREATMENT:
Day 1
1. IVF NS 150 ml /hr
2. Inj. PANTOP 40 mg iv /OD
3. Inj. Zofer 4mg IV/SOS
4. Inj.Tramadol 1 Amp in 100 ml NL iv/BD
5. Tab PCM 500 mg PO/SOS
6. Inj.METROGYL 400 mg iv /TID
7. Monitoring Vitals 4th holy
8. I /O charting.
Day 2
Pain abdomen decreased
1 episode of stool associated with blood
Day 3
Pain abdomen subsided
No episodes of loose stools
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