48 year old male with vomitings and pain in the abdomen

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.



CASE PRESENTATION:

A 48 year old male came to casualty with c/o
Vomiting since 1day
Pain abdomen since 1 day

HOPI:

Patient was apparently asymptomatic 1 day back then he developed vomitings (20 episodes-non projectile, non bilious)
He also had pain in the epigastric region which is non progressive,  non radiating. 
No h/o fever/head ache
No h/o cough/cold
No h/o constipation/loose stools
No h/o Burning micturition 
No h/o bleeding manifestations 

PAST HISTORY:

Not a k/c/o DM/HTN/TB/ASHTMA/EPILEPSY/CAD 

Personal History :

Diet : mixed
Appetite : Normal 
Sleep : Adequate 
Bowel movements : Normal 
Bladder movements : Normal


On Examination :

Patient is conscious, coherent and cooperative.
Pallor -Absent
Icterus -Absent
Cyanosis -Absent
Clubbing -Absent
Lymphadenopathy -Absent
Edema -Absent








VITALS :
AT THE TIME OF ADMISSION :
TEMP. : 98.7 F
PR : 96 BPM
RR : 18 CPM
BP : 120/80 MM HG



On Systemic Examination:

CVS : S1, S2 heard
RS : BAE present
P/A : soft, Tenderness present in epigastric region 
CNS : HMF Intact

INVESTIGATIONS:

On 11/11/2022:



















PROVISIONAL DIAGNOSIS:? ACUTE PANCREATITIS SECONDARY TO ALCOHOL 


TREATMENT:

1.NBM

2.IV FLUIDS NS@100ML/hr DNS@50 ml/hr

3.INJ.TRAMADOL IV/TID in 100 ml NS over 30 mins

4.INJ.OPTINEURON 1amp in 100 ml NS IV/OD

5.INJ.PAN 40 MG/IV/BD

6.INJ.ZOFER 4MG/IV/TID

7.NEB.WITH DUOLIN ,BUDECORT 6 TH HOURLY 

8.GRBS CHARTING 

9.VITALS MONITORING 


​

Comments

Post a Comment

Popular posts from this blog

A 26year old Patient came to casuality with shortness of breath

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. A 26 year old male patient, resident of adauidulpally, Nalgonda district farmer by occupation came to our hospital with chief complaints of - 1. Shortness of breath 2. Loss of appetite 3. Low grade Fever  4. Pedel edema Date of admission :- 05/04/2022 History of present illness: - Patient was apparently normal 1week back , then he had one episode of low grade fever, Generalized body pains, burning micturtion but relieved with medication.Then developed pedal edema,initially till ankle Loss of appetite  4-5 days back associated with nausea and  4 days back one episode of vomiting  Non bilious and no food par
Read more

50 year old female with fever ,thrombocytopenia

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. CASE PRESENTATION: A 50 year old female came to casualty  with c/o Fever since 7 days  HOPI : Patient was apparently asymptomatic 7 days back then she developed fever which is  of high grade,intermittent, not  associated with chills and increased during night.2 days later She went to a local hospital where she was diagnosed with typhoid.she was on medication. Her platelets count reduced and fever is not subsided.  She also complained of mild head ache since 4 days ,relieved on medication  No h/o nausea, vomiting  No h/o loose stools/constipation  No h/o pain abdomen No h/o Burning micturition  PAST
Read more