Acute pancreatitis . General medicine Assignment

This is G.Chaitanya  , 8 th sem student .This Elog depicts patient centred approach to learning. 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 comprehencing clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

A 40 yr old male patient , resident of miryalguda , who is daily wage labourer by occupation came to OPD with 
cheif complaints ::-
Pain abdomen since 5 days associated with fever since 2 days .
History of present illness ::-
Patient was apparently asymptomatic 5 days ago then he developed pain which is insidious in onset and gradually progressive which is diffuse , squeezing type and radiating to back .Pain is relieved on medication .
No C/O of vomitings , loose stools , burning micturition ,cough,cold , chest pain , SOB .

History of past illness
N/K/C/O TB , hypertension, Dm, Asthma, epilepsy , CAD, thyroid disorders .
Personal history 
Diet - mixed 
Appetite- normal
Bowel and bladder -regular
Sleep - adequate
Addictions - regular alcohol intake of 250 ml per day since 20 yrs .
No food allergies and drug allergies
Family history 
Not significant
General examination
Pallor - yes 
Edema - no 
Clubbing - no 
Lymphadenopathy - no 
Icterus - no 
Vitals - 
Temperature - 100.1F
BP-85/60
Spo2- 98%
RR-20pm
PR- 100/min
Systemic examination

Per abdominal examination:

Patient exposed from nipple to mid thigh and examined in supine position 

INSPECTION: 

  • Shape:Distended flanks full 

  • Umbilicus:inverted,vertically drawn down

  • Skin over the abdomen is shiny

  • No visible peristalsis,


  • Palpation:

    On superficial Palpation 

    • All inspectory findings are confirmed 

    • Tenderness+

    • ,diffuse all quadrants

    • No Rebound tenderness 

  • No guarding,rigidity

    .Percussion

    Shifting dullness  absent 

    fluid thrill absent 

    Liver span-12cm

    Percussion of spleen : dullness in 9th inter coastal space of anterior axillary line 

    .Ascultation

    Bowel sounds+

    No arterial bruit,


    RESPIRATORY SYSTEM 

    Inspection 

    • Shape of chest:Bilaterally symmetrical,Elliptical in shape

    • No visible chest deformities

    • Abdomino thoracic respiration,No irregular respiration

    • No tracheal shift

    • No dropping of shoulders, on both sides,no sinuses,scars,engorged veins


    Palpation:inspectory findings confirmed by Palpation 

    • Chest movements -normal


Percussion:

Resonant note heard over all areas 

Auscultation: 

Norma vesicular breath sounds

, breath sounds normal 


Cardiovascular system:

Inspection:precordium normal,apex beat :5th ICS half inch medial to mid clavicular line

Palpation:inspectory findings confirmed,No thrills or parasternal heave


Auscultation: S1S2+,no murmurs


CNS:


 - 
patient is arousable 

No signs of meningitis 

cranial nerves intact,motor and sensory examination normal

No cerebellar or meningeal signs

Reflexes:

Knee         3+.     3+

Reflexes          Rt.  Lt 
Biceps               3+.   3+
Triceps              3+.    3+
Supinator          2+.    2+
Knee                  3+.     3+

              Right.        Left 
UL.        2/5.        3/5
LL.          2/5.      3/5

Investigations:











 provisional diagnosis 
 ACTUE PANCREATITIS ( non necrotizing type) PERIPANCREATIC FLUID COLLECTION.
Treatment::-
1 .IV fluids 125ml/hr 
2.inj.zoffer 4 mg IV
3.inj Tramadol 1 ampoul in 100ml NS
4.inj piptaz 4 to 5 mg 
5. Inj pan 40 mg IV
6.inj neomol 1gm IV

Comments

Post a Comment

Popular posts from this blog

A 13 yr Male with Redness of eyes,Fever, Burning micturition and swelling of cheeks

Image
A 13yr old male  who is student brought by parents with complaints of Redness of eyes since the 5days Fever since 4days Burning micturition since 4days  History of present Illness: Patient was apparently asymptomatic 5days   back after   which he developed Redness of eyes,followed by Fever which is high grade  insidious onset, gradually progressive associated with burning micturition. H/o yellowish discoloration of eyes 3days H/o swelling in both cheeks since 2days  H/o pain and difficulty in flexing left knee since 2days associated with progressive swelling No H/o recent travel  No H/o  similar complaints in the past  PAST HISTORY  N/k/c/o DM, Hypertension,  TB, Epilepsy,CVD, Asthama,Thyroid disorders PERSONAL HISTORY Single Student Diet :Mixed Appetite: Lost Sleep: adequate Bowel and bladder regular Addictions No  No known Allergies  GENERAL EXAMINATION Pt is conscious coherent and cooperative  Icterus present No  pallor, cyanosis, clubbing generalized lymphadenopathy, edema  Vitals
Read more

54 yr old male DIABETIC FOOT

Image
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 29 NOVEMBER 2023 A 54 yr old male Patient came to causality with complaints of Fever since 5 days SOB since 5 days Vomiting for 3 days History of present Illness::-  The patient was apparently asymptomatic 5 days back then he developed fever, which is of high grade associated with chills and rigors.not relieved on taking medication . He complaints of Shortness of breath since 5 days, which is grade lll  No orthopnea and paroxysmal nocturnal dyysuria. Also presents with vomitings since 3 days,2-3 episodes of per day which is non bilious, non blood stained , watery, episodes. Th
Read more