LIKITHA’S ELOG

Hello everyone! This is Likitha, an intern posted very recently in General medicine department. 


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. 


This E log book also reflects my patient-centered online learning portfolio.


CASE-

A 35 year old man from Nalgonda who is a cook by occupation came with the chief complaint of  pain abdomen since morning 6 am (06/08/20).


HISTORY OF PRESENT ILLNESS:-

•C/o pain abdomen since morning 6am at epigastric region which is sudden in onset, progressive, colicky type of pain( every 15-20mins) 

•Aggravated on lying down, comfortable on lying sideways, radiating to back.

•Associated with episodes of vomiting - Non bilious, non blood stained, non projectile , containing food particles, associated with nausea 

•Last alcohol intake- yesterday (5/08/20)

Since lockdown patient is consuming daily 90ml of alcohol. 

•H/o similar complaints every year and hospital admission 2015,2016, 2017 (3 episodes)

•No h/o fever, loose stools, shortness of breath, oliguria.


PAST HISTORY:-

K/c/o HTN since 2 years -Amlodipine 5mg, Atenolol 50mg/ OD 

K/c/o seizure disorder - Phenytoin 100mg/ PO/HS since 3 years 

No past surgical history


PERSONAL HISTORY:-

Diet-mixed

Appetite-normal

Sleep- adequate

Bowel & bladder movement- regular

Addictions- alcohol since 20years 

Betel nut consumption - since 15 years (10-15 packets daily)


FAMILY HISTORY:- 

The patient has a family history of HTN (father)


DRUG HISTORY:- 

Not significant 


GENERAL EXAMINATION:-

Patient is conscious, coherent and cooperative.

Moderately built and nourished.

Vitals -  

Temp- Afebrile 

Bp- 160/110mmHg

PR- 78bpm

RR- 18cpm 

No pallor, icterus, cyanosis , clubbing, pedal edema, lymphadenopathy.


SYSTEMIC EXAMINATION

PER ABDOMEN-

Shape - scaphoid 

Tenderness is present in epigastric region 

No local rise of temperature

No palpable mass 

No organomegaly

Hernial orifices free

Bowel sounds present




RS- 

Position of trachea central

NVBS +

No wheeze 

No adventitious breath sounds 


CVS- 

S1S2 heard

No murmurs 

Apex beat not felt


CNS-

Higher mental functions intact. 

All cranial nerves intact.

Sensory- intact 

Motor - intact 

No cerebellar signs



INVESTIGATIONS

 

•Ultrasound


•CECT 
 
  


•ECG


 •Other investigations






Fever charting: 


Diagnosis:-

Acute necrotising pancreatitis 


TREATMENT:-

•Nil by mouth until further orders

• IV fluids 

• Inj PAN 40mg IV BD

• Inj ZOFFER 4mg TID

• Inj TRAMADOL 1Amp in 100ml NS IV 6th hourly 

•Tab Phenytoin 100mg OD


Comments

Post a Comment

Popular posts from this blog

LIKITHA’S ELOG

Image
Hello everyone! This is Likitha, an intern posted in General medicine department.   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.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome. Here is a case which I have seen:- A 50 year old male patient came to the opd on 27/08/20. Patient was apparently symptomatic 10 years back. Patient first went to the hospital with c/o fever, giddiness and sweating. Then local doctor observed high blood sugars and started on OHA 10 years back.  Later he had h/o trauma on 2nd toe of Rt LL 1 year back. Gradually his 3rd and 4th toes of R
Read more

LIKITHA’S ELOG

Image
  Hello everyone! This is Likitha, an intern posted in General medicine department.   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.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome. Here is a case which I have seen:- A 38 year old male patient has come to the opd on 04/09/20. He had 2 episodes of involuntary movements of both upper limb and lower limb with frothiness from mouth, up rolling of eyes which lasted for 2 minutes.  No  h/o involuntary micturition and tongue bite. No h/o chest pain, shortness of breath, weakness and deviation of mouth. The patient had
Read more

Biweekly exam

 1)Anatomical diagnosis -? Glomerulosclerosis                                                                        Etiological diagnosis -  ?? Nephrotic syndrome secondary to the diabetic nephropathy or CKD.     2)Reasons for I) Azotemia : impaired renal excretion of urea and creatinine secondary to CKD.  II) Anemia : decreased erythropoietin.  III) Hypoalbunemia: capillary basement membrane and podocytes damage.  IV)  acidosis: acidification of urine is lost.                                       3) Rationale : syp potchlor was given because of the hypokalemia.. Inj. NaHCO3 was given because of metabolic acidosis ..Insulin and antihypertensives are given because known case of DM and HTN. Orofer XT was given because of anemia.. Inj. Lasix was given to decrease her volume overload. Spironolactone was given it was a potassium sparing diuretic.Calcium was given to the patient  because of hypocalcemia secondary to CKD. Indications of NaHCO3:metabolic acidosis in cardiac arrest, Tricyclic
Read more