General medicine case discussion
E LOG MEDICINE CASE
20/10/2022
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Name : Kavya dharshini.s
Roll no : 58
2k20Batch
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 comeup with Diagnosis and Treatment plan.
CASE DISCUSSION:
Date of admission 19.12.22
A 30 year old male came to opd who is daily wage worker came with ,
CHEIF COMPLAINTS:
Pain abdomen since 3 days
There is a history of vomiting on date 15/10/2021 and 18/10/2021.
HISTORY OF PRESENTING ILLNESS:
Daily routine before presenting to hospital:
He usually get up at 5:00am then at round 6:00am he goes to the work he skips the breakfast and he eat directly the lunch (rice with some curry) or he skips the lunch.
He comes to the home at around 8:00 pm from the work.
There is decreased appetite .He eats only twice in the day
He is a chronic alcoholic since 10years ,he drinks daily at around 180ml/day.
He smokes occasionally since 10 years.
He chews gutkha daily since 10 years.
Patient also mentioned that he drinks lots of water like in between 10-15 litres.
Recently before coming to hospital:
On 15th of October he taken more amount of alcohol at around (720 -870ml )then he had an 2 episodes of vomiting in the evening which is non projectile,bilious,non blood stained.
and he also complained of fever on 17th october for which he taken medication from local RMP
On 18/10/2021 he complained pain abdomen which is insidious in onset, graduallyprogressive,continuous (present whole day)which is squeezing type of pain,no aggravating factors,he taken medications from local RMP but it does not get relieved.
On 18/10/2021 patient is taken to the nalgonda government hospital where symptoms were not relieved ,on 19/10/2021 they went to private hospital as it is a private hospital they cannot afford so the patient referred here.
After coming to the hospital:
He developed shortness of breath on 20/10/2021, afternoon.
PERSONAL HISTORY:
Appetite: Decreased appetite
Diet:Mixed
Bowel and Bladder habits:regular
Addictions:
He is chronic alcoholic since 10 years ,he drinks daily at around 180ml/day
He smokes occasionally since 10 years
He also chews gutkha everyday since 10 years.
PAST HISTORY:
There is no history of DM,HTN,TB, EPILEPSY.
No history of blood transfusions.
No history of previous surgeries.
FAMILY HISTORY:
Insignificant
GENERAL EXAMINATION:
Conscious, coherent, co-operative
Moderately built,nourished
PALLOR: ABSENT
ICTERUS:ABSENT
CYANOSIS: ABSENT
CLUBBING OF FINGERS/TOES: ABSENT
LYMPHADENOPATHY: ABSENT
PEDAL EDEMA: ABSENT.
VITALS:
TEMPERATURE: Afebrile
PULSE RATE:99 beats /min
RESPIRATORY RATE:22 Cycles/min
BP:170/90mm of hg
SPO2:99% at room air
GRBS:1 mg%
SYSTEMIC EXAMINATION:
CVS:
S1,S2 Sounds heard,
No audible murmurs,
Thrills:No.
RESPIRATORY SYSTEM:
Dyspnea is present,
Position of trachea:central,
Normal vesicular breath sounds are heard,
No adventitious sounds
P/A :
Inspection:
*Abdomen is tense and distended
*Umbilicus is slit shaped
* movement of abdomen moves equally with respiration
* No visible scars.
Palaption:
* No local rise of temperature
* tenderness present
* No palpable masses found
* Liver and spleen are not palpable
Percussion :
* Shifting dullness present
* Liver span: normal
Ascultation:
* bowel sounds are heard
INVESTIGATIONS:
19/10/2021;
COMPLETE URINE EXAMINATION:
19/10/2021;
LFT:
COLLECTED SAMPLE AT 7:00PM
LFT:
COLLECTED SAMPLE AT 2:39PM
USG (OUTSIDE) :
ECG,
On 17/10/2021,
PROVISIONAL DIAGNOSIS :
ACUTE PANCREATITIS (SECONDARY TO ALCOHOL) WITH MIN LEFTSIDED
PLEURAL EFFUSION and mild ascites.
TREATMENT:
On 19/10/2021 ;
Inj.PAN in NS 500ml 80mg/iv/stat
Inj.TRAMADOL 1amp in100ml NS/iv/stat
Inj.HVT in NS 500ml 1amp/iv/stat
Inj.XOFER 4mg/iv/TID
Inj.LASIX 90mg IV/STAT
Inj.BUSCOPAN IV/SOS
NBM till further orders
Strict BP,PR monitoring 2nd hourly
Strict I/O monitoring.
On 20/10/2021 ;
IVF NS 150ml/iv/hr
IVF RL 150ml/iv/hr
Inj .PANTOP 40mg/iv/hr
Inj.TRAMADOL 1amp in 100ml of NS/IV/BD
Inj.ZOFER 4mg/iv/TID
Inj.BUSCOPAN IV/SOS
Patient left gainst medical advice(LAMA).
