48 year old male with vomitings pain abdomen

 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.



CASE PRESENTATION:

A 48 year old male came to casualty with c/o
Vomiting since 1day
Pain abdomen since 1 day

HOPI:

Patient was apparently asymptomatic 1 day back then he developed vomitings (20 episodes-non projectile, non bilious)
He also had pain in the epigastric region which is non progressive,  non radiating. 
No h/o fever/head ache
No h/o cough/cold
No h/o constipation/loose stools
No h/o Burning micturition 
No h/o bleeding manifestations 

PAST HISTORY:

Not a k/c/o DM/HTN/TB/ASHTMA/EPILEPSY/CAD 

Personal History :

Diet : mixed
Appetite : Normal 
Sleep : Adequate 
Bowel movements : Normal 
Bladder movements : Normal


On Examination :

Patient is conscious, coherent and cooperative.
Pallor -Absent
Icterus -Absent
Cyanosis -Absent
Clubbing -Absent
Lymphadenopathy -Absent
Edema -Absent








VITALS :
AT THE TIME OF ADMISSION :
TEMP. : 98.7 F
PR : 96 BPM
RR : 18 CPM
BP : 120/80 MM HG



On Systemic Examination:

CVS : S1, S2 heard
RS : BAE present
P/A : soft, Tenderness present in epigastric region 
CNS : HMF Intact

INVESTIGATIONS:

On 11/11/2022:


















On 12/11/22






PROVISIONAL DIAGNOSIS:? ACUTE PANCREATITIS SECONDARY TO ALCOHOL 


TREATMENT:

1.NBM

2.IV FLUIDS NS@100ML/hr DNS@50 ml/hr

3.INJ.TRAMADOL IV/TID in 100 ml NS over 30 mins

4.INJ.OPTINEURON 1amp in 100 ml NS IV/OD

5.INJ.PAN 40 MG/IV/BD

6.INJ.ZOFER 4MG/IV/TID

7.NEB.WITH DUOLIN ,BUDECORT 6 TH HOURLY 

8.GRBS CHARTING 

9.VITALS MONITORING 
























Comments

Post a Comment

Popular posts from this blog

Medicine assignment

Image
Medicine assignment for the month of May 2021 Name: E.Laharika  Roll no: 29 I have been given the following cases to solve in an attmept 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 diagnosis and coem up with a treatment plan. This is the link of the questions asked regarding the cases:       http://medicinedepartment.blogspot.com/2021/05/online-blended-bimonthly-assignment.html?m=1 Below are my answers to the Medicine Assignment based on my comprehension of the cases.  FIRST CASE(NEUROLOGY) A 55 year old female patient, a resident of Miryalaguda and farmer by occupation  came to the hospital on 17/5/21  with the  chief complain ts   of  shortness of breath, pedal edema and facial puffiness  https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html 1) What is the evolution of the symptomatology in this
Read more

65 yr old male with fever,dry cough and generalised weakness

Image
  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. CASE PRESENTATION: A 65 year old male came to casualty  with c/o Fever since 20 days  Cough since 10 days Generalised weakness since 10 days HOPI : Patient was apparently asymptomatic 20 days back then he developed fever which is  of high grade,intermittent,  associated with chills and no diurnal variation.  He  had Cough since 10 days which is associated with sputum which is white in colour He also had loss of appetite and generalised weakness No h/o nausea, vomiting  No h/o loose stools No h/o constipation  PAST HISTORY : K/C/O TB 1 year back(used medication for 6 months) Not a K/C/O DM/HTN Person
Read more

54 yr old male with dyselectrolytemia

Image
  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. CASE PRESENTATION: A 54year old male ,came  with complaints of Hiccups since 4 days  Decreased Apetite since 4 days Generalised weakness since 4 days HOPI : Pt was apparently asymptomatic 7 years back and then had history of trauma to foot which was not healing went to hospital and was diagnosed as having diabetes initially on OHA and later changed to insulin (MIXTARD) Patient has similar complaints 8 months ago and 4 months ago and 1 month ago developed similar complaints of hiccups and was in altered sensorium and was diagnosed as altered sensorium secondary to dyselectrolytemia and CKD(Diabetic n
Read more