General medicine practicals


A 67 yr old male patient farmer by occupation resident of AP lingotam came to OPD with complaints of pain abdomen since 4 days
Chief complaints
Pain abdomen since 4 days 
History of present illness
Patient was apparently asymptomatic 4days ago then he developed pain in abdomen which is insidious in onset,gradually progressive ,dragging type,aggravated on doing work,after consumption of alcohol,not associated with nausea,vomitings
No history of constipation
 h/o burning micturition
No h/o fever,cough,cold
Past history
N/k/c/o HTN,asthma,epilepsy,TB,CAD,CVA
No h/o surgeries in the past
No h/o blood transfusion
No h/o radiation exposure
Recently diagnosed with Diabetes
Personal history
Diet :mixed
Appetite: decreased since 4 days
Sleep : adequate
Bowel movements : regular
Burning micturition
Addictions: regularily consumes alcohol
               About 90ml/ day 
                Since 30 years 
General examination
Patient is conscious, coherent, cooperative and well oriented to time and place 
Moderately built and nourished 
Pallor present,icterus present ,no cyanosis,clubbing,lymphadenopathy and pedal edema 
Vitals 
Bp: 130/80mmHg
Pulse rate : 69bpm
RR: 20/ min
Systemic examination
Cvs S1,S2 heard
CNS no focal neurological deficits noted
RS bilateral air entry present ,normal vesicular breath sounds 
Per abdomen 
Inspection:
Abdomen is flat ,no scars,sinuses, hernial orifices,pulses,masses
All quadrants are moving equally with respiration
Palpation 
All inspectory findings are confirmed on palpation
Abdomen is soft
Tenderness is present in epigastric and both hypochondriac region 
No local rise of temperature
Percussion
No fluid thrill/shifting dullness/puddles sign
Tympanic note heard
Auscultation
Bowel sounds are heard 
Provisional diagnosis
Acute on chronic pancreatitis
Investigations

Chronic pancreatitis

 DAY 1 

S : c/o pain abdomen

No nausea, vomitings 

No fever spikes 

O : O/E pt is c/c/c 

Temp 

PR. 69 bpm

Bp. 120/70 mm hg 

Spo2 97 % at RA

GRBS 192 mg/dl

RS BAE + ,NVBS,No added sounds 

P/A : Guarding+ , tenderness+ bowel sounds heard 

Cvs s1,s2 heard 

No murmurs

CNS NFND

A : acute on chronic pancreatitis 

P: NBM untill further orders 

IVF ns @ 100 ML/hr 

Inj ceftriaxone 2 g /IV / BD 

INJ METROGYL 500 mg IV /TID

Inj thiamine 200 mg in 100 ML NS IV/tid 

Inj Tramadol 100 mg in 100 ML NS IV/BD 

INJ PAN 40 Mg IV /OD 

INJ ZOFER 4 Mg IV /BD


Comments

Post a Comment

Popular posts from this blog

general medicine practicals

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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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 comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan Chief complaints : b/l pain in lower limbs upto knees since 20 days  B/l swelling in the leg since 20 days  HOPi : Pt was appently asymptomatic 3 yrs back then he developed sudden pain in right sid...
Read more

General medicine

Image
Ch Janani Roll no. 29 A female patient aged 74 yrs  came to the OPD with chief complaints of fever  ,shortness of breath ,and she had altered sensorium. Chief complaints Fever ( 7 days) Shortness of breath(4 days ) Altered sensorium ( 2-3 days) History of present illness Patient was apparently asymptomatic 10 days back and She was admitted to hospital by her family due to loss of consciousness,fever,loss of speech and altered sensorium. History of past illness N/k/c/o diabetes mellitus,CAD and CVA hypertension,TB, epilepsy,no previous surgeries. She is a known case of asthma using inhalers ( duration not known) Personal history She is married Diet : mixed Bowel and bladder movements: normal  Appetite: normal No allergies No addictions Drug history: used pain killers for pain and swelling of lower limbs General examination  Palor No cyanosis No icterus No clubbing of fingers Pedal edema present ( pitting type )  Moderately built No Lymphadenopathy Vitals   T...
Read more

case 1

Ch Janani Roll no .29 A 28 yr female patient resident of Surat came to OPD with chief complaints of left side flank pain, shortness of breath and dysuria. Cheif complaint Left side flank pain Dyspnoea One episode of hematuria and dysuria History of present illness Patient was apparently asymptomatic 15yrs ( i.e in 2007 ) she had complaints of loss of weight and appetite for which she was diagnosed as pulmonary tuberculosis and on started on anti tubercular therapy .But she discontinued the treatment and she was kept of 8 months ATT.and in 2020 she developed low back ache for which she was diagnosed as renal calculi.now she came to our hospital with c/o left flank pain , dyspnoea grade 2,one episode of hematuria. History of past illness Hematuria,k/c/o tuberculosis in childhood No h/o of diabetes , hypertension, epilepsy and no previous surgeries. Personal history Married Appetite:normal  Diet : mixed  Bowels: irregular  Micturition:normal  Non alcoholic non smoker an...
Read more