case 2
This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation.
A 37 yr old male auto driver came to the Casuality with the chief complaints of severe abdominal pain since 3 days
1) History of presenting illness:-
Patient was apparently asymptomatic 3 days back then he developed gas with stomach pain since 3 days.
He developed very severe pain in the abdomen on 16th march at around 1 am ( night ), he developed the pain after passing the stools at mid night and then he consumed quarter alcohol after passing stool. Pain initially started in the epigastric region and gradually there was increase in pain by morning 6 AM which was radiating towards left hypochondriac region and also radiating backwards . Pain was squeezing type.
Pain was associated with 3 episodes of vomiting in a day, presence of food particals in the content of vomitus and it was bilious type.
Patient initially thought as heart problem and referred to cardio physician in Nalgonda and doctor over there informed him that he is not having any heart problems. Patient came to our hospital for further evaluation and treatment.
) past history :-
No similar complaints in the past
Previously diagnosed with hypertension 3 months back.
History of kidney infection 2 years back and took medication.
No history of DM, TB, epilepsy, asthma.
3) family history :-
- no significant family history
4) personal history :-
- Diet - mixed ( veg and non veg )
- Appetite - reduced
- Sleep - adequate
- Bowel and bladder movements - regular
- Addictions - alcoholic since 15 years and consumes a quarter daily
- He smokes 4 cigarettes per day since 10 years
- he also consumes 10 to 15 packets of gutka from past 10 years
Allergies - No known food or drug allergies
5) Treatment history :-
Patient was diagnosed with hypertension 3 months back at Nalgonda government hospital , he was told to continue medication but patient used medication for one week and discontinued.
) past history :-
No similar complaints in the past
Previously diagnosed with hypertension 3 months back.
History of kidney infection 2 years back and took medication.
No history of DM, TB, epilepsy, asthma.
3) family history :-
- no significant family history
4) personal history :-
- Diet - mixed ( veg and non veg )
- Appetite - reduced
- Sleep - adequate
- Bowel and bladder movements - regular
- Addictions - alcoholic since 15 years and consumes a quarter daily
- He smokes 4 cigarettes per day since 10 years
- he also consumes 10 to 15 packets of gutka from past 10 years
Allergies - No known food or drug allergies
5) Treatment history :-
Patient was diagnosed with hypertension 3 months back at Nalgonda government hospital , he was told to continue medication but patient used medication for one week and discontinued.
) past history :-
No similar complaints in the past
Previously diagnosed with hypertension 3 months back.
History of kidney infection 2 years back and took medication.
No history of DM, TB, epilepsy, asthma.
3) family history :-
- no significant family history
4) personal history :-
- Diet - mixed ( veg and non veg )
- Appetite - reduced
- Sleep - adequate
- Bowel and bladder movements - regular
- Addictions - alcoholic since 15 years and consumes a quarter daily
- He smokes 4 cigarettes per day since 10 years
- he also consumes 10 to 15 packets of gutka from past 10 years
Allergies - No known food or drug allergies
5) Treatment history :-
Patient was diagnosed with hypertension 3 months back at Nalgonda government hospital , he was told to continue medication but patient used medication for one week and discontinued.
GENERAL EXAMINATION :-
- patient is conscious,cooperative and coherent and well oriented to time, place and person.
- He is moderately built and moderately nourished.
- He was examined after taking consent.
Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
lymphadenopathy - absent
Oedema - absent
Vitals :-
●Pulse rate - 101 bpm
●Bp - 140/80 mm/hg
●Temperature - afebrile
●Respiratory rate - 17 cycles per minute
●SpO2 - 98% at room air
SYSTEMIC EXAMINATION .:-
●CARDIOVASCULAR SYSTEM -
- S1 , S2 heard
- no murmurs and no thrills
●RESPIRATORY SYSTEM-
-Position of trachea is central
-Bilateral Normal vesicular breath sounds
●CNS-
- higher motor functions are intact and no focal neurological deficits
ABDOMEN-
- shape of abdomen is rounded due to visceral fat
- soft and tender in the epigastric region, left hypochondriac region and left lumbar region
- no palpable masses
- liver and spleen are not palpable
- decreased bowel sounds.
INVESTIGATIONS:-
Hemogram
ESR
Blood sugar ( random)
Blood sugar ( fasting )
Live function test
Renal functional test
Serum amylase
Serum lipase
HBsAg - negative
HIV - negative
HCV - negative
Ultra sound:_
-Bulky head and body of pancreas with altered echo texture .
- grade 1 fatty liver.
PROVISIONAL DIAGNOSIS - acute pancreatitis and de novo diabetes mellitus
Treatment:-
Nill per oral and rules tube is inserted.
IVF - 2Normal saline / ringer lactate at 100ml per hour
Injection zofer 4mg/IV
Injection pantop 40mg/IV- OD
Injection tramadol 1amp + 100ml NS / IV / BD
Injection thiamine 2amp + 10ml NS / TID
Discoloration of teeth:
