CBBLE UDHC SIMILAR CASES

 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 



A 47 year old lorry driver  came with c/o pain abdomen since today 3 am (23/2/2022).

Hopi:
Patient was apparently  asymptomatic 14 years back, went to hospital for regular check up and was diagnosed with DM -2  and since then he is on OHA’s , Gilmi M2 po/bd. 
10 years back on routine check up he came to be diagnosed with HTN and he is on TELMA - H / OD . 
20 years back diagnosed with renal calculi ,pain- operated
4.5 years back , patient c/o abdominal full ness , associated with  tightness , squeezing type , relieved with vomitings  associated with  vomitings  bilious  associated with food particles 
Patient is having similar episodes every once in  a year
Patient is chronic alcoholic since 20 -25 years, whiskey ( 90-180 ml) / every day , 4-5 times / week 
Fever , burning micturition since 5 days 
Last binge 4-5 days back , 90 ml whiskey 
No c/o chest pain , palpitations , syncopated attacks

Past history:
k/c/o Dm since 14 years and on tab gilmi - m2 
k/c/o HTN since 10 years and on tab telma-h /OD 
n/k/c/o Tb , bronchial asthma , cad, 

Surgical history: previously had surgery for hernia 


Personal history:
Married 
Lorry driver  by occupation 
Appetite:normal
Bowel bladder movements: regular 
Addictions: alcohol consumption since 20-25 years , whiskey,(90-180 ml)/ every day ,4-5 times / week 
90-180ml ,whiskey per day 

Family history: not significant 

O/e:
Pt is c/c/c,well oriented to time,place,person
No signs of pallor,icterus,clubbing,cyanosis,lymphadenopathy,pedal edema.
Vitals:
Temp:101 F 
Pr:97 bpm 
Rr:17 cpm
Bp:140/100
Grbs:86 mg /dl

Systemic examination:
Cvs: S1,S2 heard
Rs:BAE +
P/A: rigid, tenderness in epigastric region 
Cns: NAD

Investigations:(23/2/2022)

Haemogram:
Hb-15.2
Tlc-10,600
N/L/E/M-87/06/01/06
Pcv -41.5
Plt-1.60
Imp- normocytic normochromic with neutrophilia 

Cue:
Albumin- trace
Sugar- + +
Pus cells- 3-4

Urea - 29
Serum creatinine - 0.9
Sodium -135
Potassium-3.4
Chloride -103

Tb-3.38
Db-1.91
Sgot-328
Sgpt-182
Alkaline phosphate -245
Total proteins-6.4
Albumin-3.9
A/G ratio-1.56

ABG:
Ph- 7.38
PCO2- 23.5
PO2-86.6
HCO3-13.8
 
Serum amylase- 185
Lipase-89
 
Hba1c-6.9 

25/2/22

Tb-3.78
Db-2.82
Sgot-88
Sgpt-101
Alkaline phosphate -225
Total proteins-6.2
Albumin-3.6
A/G ratio-1.41

Haemogram:
Hb-14.7
Tlc-5,100
N/L/E/M-70/18/4/8
Plt-85.4
Imp- normocytic normochromic 


Pt-19
Aptt-38
Inr-1.4

CHEST X RAY:




Usg- 
Imp-1)Acute on chronic pancreatitis 
        2)Left renal calculi 

Cect abdomen-
Imp-1)chronic calculus pancreatitis 
        2) Bilateral small renal calculi 
        3)Gall bladder wall edema- reactive



TREATMENT:
1.Ivf with ns and rl @ 100 ml/hr 
2.NBM till further order
3.Inj pan 40mg/iv/bd
4.inj zofer 4mg/iv/tid
5.inj tramadol 1amp in 100ml ns /iv/tid
6.tab telma -h /od 
7.inj thiamine 1amp in 100ml ns/iv/tid
8.inj  hai s/c tid acc to sliding scale 
8.strict input output charting 

Diagnosis: Acute  on chronic pancreatitis with Dm since 14 years  and Htn since 10 years

Comments

Post a Comment

Popular posts from this blog

E log book sravya busetty 32

General medicine case discussion  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 icluding history,clinical findings,investigations and come up with a diagnosis and treatment plan. You can find the entire real patient clinical problem in this link below.....( https://classworkdecjan.blogspot.com/2019/05/42-f-with-severe-regular-edema-with_17. A case of a 42 year old female patient with multiple health events since birth came to the department with cheif complaints of Headache with aura Swelling of face and abdomen  Rash Sleep disturbances  Decreases frequency of urination And the reason i found for the problems are: 1.headache:it is sudden in onset gradually progressive associated with aura and numbness on left side,stuttering of speech was there with vomiting Probable diagnosis: 1. Hemiplegic migraine 2.Brain neuro
Read more

CBBLE UDHC SIMILAR CASES

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 patients clinical problems with collective current based inputs. Unit 3 & 6 Amc bed 5 Chief complaints: Patient came to casualty with complaints of pain in abdomen from today morning  History of presenting illness: 55yr/M barber by occupation was apparently asymptomatic 15 years back then he had c/o pain abdomen diagnosed as intestinal perforation discharged after 1 week and again he complains of abdominal pain since today morning which was in midline between epigastric and umbilicus squeezing type sudden in onset progressive, aggravates on deep inspiration and no radiation not associated with nausea and vomiting.also have c/o chest pain , epigastric region burning type
Read more

CBBLE UDHC SIMILAR CASES

Image
 GENERAL MEDICINE CASE "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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcomed January 19, 2022 23Y/M WITH VOMITINGS AND LOOSE STOOLS GENERAL MEDICINE CASE "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 patients clinical problems with collective current best evidence
Read more