MEDICINE CASE DISCUSSION
MEDICINE CASE DISCUSSION
This is an E-log book to discuss our patient's de-identified health data shared after taking his 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 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 comments in comment box are most welcomed .
I have been given this case, in an attempt to solve and understand the topic of "Patient's clinical data analysis”. This has helped me develop my competency in reading and comprehending clinical data including history taking, clinical findings and investigations. The goal is to come up with a diagnosis and treatment plan.
PAVITRA BALDAWA
ROLL NUMBER -104
30th march 2022
CHIEF COMPLAINS:
28 year old male, resident of Hyderabad and tailor by occupation came to OP with C/O pain abdomen since 3 days and 2 episodes of vomitings.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 4days ago then he went to a Feast where he ate Chicken Biryani, later then he developed pain in epigastric region which was sudden in onset ,colicky type, radiating to back, the pain aggrevated on taking meals and relieves on leaning forward.
3 days back he went to the RMP because of the pain after taking medication pain decreased for 1 day, but on the next day pain increased.
Vomiting was non projectile, non bilious, with food particles as the content.
No history of loose stools, constipation, fever, trauma and weight loss.
PAST HISTORY:
No similar complains in the past.
Not a known case of DM, hypertension ,CAD ,asthma ,TB.
He underwent endoscopic examination 8 years back??
PERSONAL HISTORY:
Diet: mixed.
Sleep: disturbed sleep since 3 days.
Appetite: decreased since past 2 days
Bowel and bladder: regular.
No addictions or allergies.
FAMILY HISTORY:
No similar complaints in the family.
GENERAL EXAMINATION:
Patient was conscious, coherent and cooperative.
Moderately built and moderately nourished.
There is no pallor, icterus ,cyanosis, lymphadenopathy, clubbing ,edema.
Vitals-
Temperature: afebrile
Pulse rate:79 beats per minute
Respiratory rate:14cycles per minute
BP:110/70mmhg
Spo2:96%
GRBS:109 mg %
SYSTEMIC EXAMINATION:
CVS:
S1 and S2 are heard.
No murmurs and thrills.
Respiratory examination:
There is no dysnoea, wheeze.
Breath sounds are vesicular.
Abdominal examination:
Inspection:
Shape of the abdomen: scaphoid
Umbilicus - midline and inverted
No scars and sinuses.
No engorged veins.
Palpation:
No local rise of temperature
Tenderness is present in epigastric region.
Liver and spleen are not palpable.
Bowel sounds heard.
No guarding.
Percussion
All findings are normal
Auscultation:
bowel sounds are heard
CNS-
Sensory and Motor responses are normal.
INVESTIGATIONS:
HEMOGRAM-
HB 16.3grm/dl
TC 17,100cells/cumm (normal-4000-10000)
PLT 3.38
MCV 82.5
PCV 46
MCH 29.2
MCHC 35.4
SMEAR - NORMOCYTIC NORMOCHROMIC
BGT- O positive
RBS- 124
RFT-
Urea 50mg/dl (normal-12-42)
Creatinine 0.9mg/dl (normal-0.9-1.3)
S. Sodium 140mEq/L(normal-136-145)
S. Potassium 3.8mEq/L(normal-3.5-5.1)
S. Chloride 98mEq/L(normal-98-107)
S. Amylase 124 IU/L(normal-13-60)
S. Lipase 528IU/L(normal-25-140)
LFT-
TB 1.38mg/dl (normal 0-1)
DB 0.45 mg/dl(normal-0.0-0.2)
AST 36 IU/L(normal-0-31)
ALT 21IU/L (normal-0-34)
ALP 117IU/L(normal-42-98)
TP 6.7gm/dl(normal-6.4-8.3)
ALB 3.73gm/dl(normal-3.5-5.2)
SEROLOGY:
NEGATIVE
BLOOD SUGAR LEVELS:
RBS-124mg/dl
USG-
XRAY-
PROVISIONAL DIAGNOSIS:
Acute pancreatitis secondary to gall stones.
TREATMENT:
Inj.Tramadol in 100mlNS/IV/STAT
IVF NS/Ringer Lactate@75ml/hr
monitor vitals
Co- presenters
http://mridultak.blogspot.com/2022/03/a-28-year-old-male-with-acute.html
http://haqansariblogformonthlyassiggnment.blogspot.com/2022/03/28-year-old-male-with-acute-pancreatitis.html
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