Case of abdominal pain

 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 patient's clinical problems with collective current best evidence based inputs. 

A 38 year old male who is autodriver  by occupation came to the OPD with the chief complaints of stomach pain since 2 months.

HISTORY OF PRESENT ILLNESS:

Normal routine of the patient:

The patient wakes up by 6AM daily and he used to have his lunch by 1/2 PM (rice & curry ) and returns home by 6.30/7 in the evening. Then he used to have his dinner (rice again) and sleeps by 9 PM.

 The patient was apparently asymptomatic one year back and then he developed stomach pain which was radiating backwards and got subsided on medications given by a local doctor.

He then came to the OPD with the same complaint again.

History of past illness :

The patient is not a known case of diabetes, epilepsy, tuberculosis, asthma, hypertension


Personal history : 

- The patient has loss of appetite

- He takes mixed diet

- No sleep disturbances

- He consumes 100ml(approx)of toddy once in two weeks 

Family history :

- There are no similar complaints in the family members


Treatment history :

- He is not a known case of drug allergy.


General examination :


- Patient is conscious, coherent, cooperative at the time of joining

- No Pallor 

- Icterus present

- No cyanosis

- No clubbing of fingers and toes

- No lymphadenopathy

- No pedal edema






Vitals : temperature - afebrile 


              Pulse rate - 70 bpm


              Respiratory rate - 18 cycles per minute


              BP - 110/70 mm Hg




Systemic examination : 


CVS


Inspection - chest wall is bilaterally symmetrical


- No precordial bulge 

- No visible pulsations, engorged veins, scars, sinuses

Palpation - JVP is normal

Auscultation - S1 and S2 heard



RESPIRATORY SYSTEM


- Position of trachea is central 

- Bilateral air entry is normal

- Normal vesicular breath sounds heard

- No added sounds


PER ABDOMEN 

- abdomen is tender

- bowel and bladder sounds heard

- no palpable mass 

- patient has mild amount of fluid 


CNS

- Patient is conscious

- Speech is present

- Reflexes are normal


Investigations : 











Treatment:

24/11/21

IVF-2NS

     -1DNS 1RL 

INJ THIAMINE 1amp 

INJ PAN 40mg IV

INJ ZOFER 4mg IV

INJ TRAMAD 1amp 

BP/PR/Temp charting 

Monitor vitals 

25-11-21

IVF-2NS

INJ THIAMINE 1amp 

INJ PAN 40mg IV

INJ ZOFER 4mg IV

INJ TRAMAD 1amp 

BP/PR/Temp charting 

Monitor vitals 

27-11-21

IVF-2NS

INJ THIAMINE 1amp 

INJ PAN 40mg IV

INJ ZOFER 4mg IV

INJ TRAMAD 1amp 

BP/PR/Temp charting 

Monitor vitals 

28-11-21

IVF-2NS

INJ THIAMINE 1amp 

INJ PAN 40mg IV

INJ ZOFER 4mg IV

INJ TRAMAD 1amp 

BP/PR/Temp charting 

Monitor vitals 

Questions:

1.what are the causes of acute pancreatitis?

2.why does the pain radiate backwards in pancreatitis?

3.Can ascites occur in pancreatitis if yes,how ?

4.what happens if pancreatitis is left untreated?


Comments

Post a Comment

Popular posts from this blog

Final exam

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 patient's clinical problems with collective current best evidence based inputs A 67 yr old male patient presented to the opd with the chief complaints of shortness of breath since 2-3 days, bilateral pedal edema since 3 days, orthopnea,PND History of present illness: patient was apparently normal 20 yrs Back then he developed severe cough with sputum and also shortness of breath.then he was diagnosed with TB.he used ATT course for 9 months and relieved. Now patient again developed shortness of breath of grade 2-3, grade-2 pedal edema of pitting type. Past history: known case of TB. Not a known case of diabetes, hypertension, asthama , epilepsy. Personal history: patient follow
Read more

Case history-04

Image
  This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 patient's clinical problems with collective current best evidence based inputs.  40 year old male farmer by occupation was brought to opd with chief complaints of weakness of b/l lower limbs and upper limbs since 4 days Unable to walk since 2 days.  HISTORY OF PRESENT ILLNESS  Patient was apparently asymptomatic 4 days back and then while he was dancing in Ganesh nimarjanum he suddenly fell down due to weakness of B/L lower limbs which was sudden in onset, progressive in nature ( initially walked with support, now can't move.)  weakness now progressed to B/L upper limbs.  No h/o loss if sensations No h/o headache, giddiness, slurred speech, deviation of mouth or involuntary moveme
Read more

Case history-06

Image
October 29, 2021   This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 patient's clinical problems with collective current best evidence based inputs.  A 75 year old male who is farmer by occupation came to the OPD with the chief complaints of pedal edema and facial puffiness since 3days  HISTORY OF PRESENT ILLNESS: Normal routine of the patient: He used to get up at 6 in the morning, used to have tea then breakfast at 8 (rice) then used to go for farming, he used to have lunch at 2 which is rice again. He used to return home by 6 in the evening then he used to freshen up and have dinner at 8 PM and sleep after that. The Patient was apparently asymptomatic 3 months back then he had fever first which didn't subside even after 4 days.
Read more