70 year old female with chief complaints of pain in abdomen since 1 day
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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.
70 year old female resident of Nalgonda, Came to casualty with chief complaints of
•Pain in abdomen since 1day
•Nausea, Vomitings since 1 day
HISTORY OF PRESENTING ILLNESS :
Patient was apparently asymptomatic 1day ago, then she developed
Pain in abdomen which was sudden in onset, diffuse (more in epigastrium, Left hypochondrium), Non radiating
It was associated with Vomitings , 2-3 episodes/day, Non bilious, Non projectile
She had 8-10episodes of loose stools which got subsided on medication
H/o weight loss present
No h/o fever
No h/o Constipation
PAST HISTORY:
Known case of HTN since 10years on Tab TELMA H
Not a k/c/o DM, tuberculosis, Asthma
SURGICAL HISTORY :
Hysterectomy 20years back
PERSONAL HISTORY :
Diet -Mixed
Appetite -Normal
Bowel and bladder movements- Regular
Addictions - Chronic alcoholic since 50 years
FAMILY HISTORY :
Not significant
GENERAL EXAMINATION:
Patient is conscious, coherent, Co operative
Vitals :
BP 160/90 mm hg
PR 80bpm
RR 17 cpm
Spo2 98
No pallor, icterus, cyanosis, Lymphadenopathy
SYSTEMIC EXAMINATION:
Per abdomen :
Soft, diffuse tenderness present (more in epigastrium)
No guarding, rigidity
Bowel sounds present
Per rectal :
No anal tags, No fissures, No fistulas
Anal tone -Normal
No Melena
Cardio vascular system :
S1,S2 heard
No murmurs
Respiratory system:
BAE present
NVBS
CNS :
NAD
INVESTIGATIONS :
Hemogram :
Hemoglobin - 11.3
TLC - 6,500
N/L/M/E/B - 84/11/04/01/00
RBC -3.92
PLT - 1.89
Liver function test :
TB- 1.21
DB-0.33
ALP-300
TP-6.5
ALB -3.4
A/G ratio-1.12
Serum amylase -1359
Serum lipase - 362
Random blood sugar - 194 mg/dL
Serum urea -22
Serum Creatinine - 0.6
Serum electrolytes-
Sodium - 139
Potassium- 3.2
Chloride- 99
ULTRASOUND ABDOMEN :
1)Features suggestive of Acute pancreatitis
2)Minimal ascitis
3)Dilated CBD with mild IHBRD
DIAGNOSIS:
? Acute pancreatitis
DOA 18/04/22
70 year old female resident of Nalgonda, Came to casualty with chief complaints of
•Pain in abdomen since 1day
•Nausea, Vomitings since 1 day
HISTORY OF PRESENTING ILLNESS :
Patient was apparently asymptomatic 1day ago, then she developed
Pain in abdomen which was sudden in onset, diffuse (more in epigastrium, Left hypochondrium), Non radiating
It was associated with Vomitings , 2-3 episodes/day, Non bilious, Non projectile
She had 8-10episodes of loose stools which got subsided on medication
H/o weight loss present
No h/o fever
No h/o Constipation
PAST HISTORY:
Known case of HTN since 10years on Tab TELMA H
Not a k/c/o DM, tuberculosis, Asthma
SURGICAL HISTORY :
Hysterectomy 20years back
AMC BED 3, SOAP NOTES DAY 3:
S
Pain in abdomen, Vomitings got subsided
No fresh complaints
O
Patient is conscious, coherent, co operative
Vitals :
BP 140/80mm hg
PR 80bpm
RR 17 cpm
Spo2 98
No pallor, icterus, cyanosis, Lymphadenopathy
SYSTEMIC EXAMINATION:
Per abdomen :
Soft, mild tenderness present in epigastrium
No guarding, rigidity
Bowel sounds present
CVS :
S1,S2 heard
No murmurs
RS:
BAE present
NVBS
CNS : NAD
Hemogram :
Hemoglobin - 10.5
TLC - 7,300
N/L/M/E/B - 80/13/2/5/0
RBC -3.56
PLT - 1.50
Serum electrolytes-
Sodium - 139
Potassium- 3.2
Chloride- 99
A
Acute pancreatitis
P
1)IV FLUIDS RL,DNS @150ml/hr
2)INJ PAN 40mg IV/OD
3)INJ ZOFER 4mg IV/TID
4)INJ OPTINEURON 1amp in 100ml NS IV/OD
5)Strict I/O charting
6)GRBS 6th hourly
7)Monitor vitals
8)INJ TRAMADOL 1Amp in 100ml NS IV/OD
9)Sips of water can be given
