70 year old female with chief complaints of pain in abdomen since 1 day

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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


Popular posts from this blog

GENERAL MEDICINE FINAL PRACTICAL 1601006026 SHORT CASE

Image
HALL TICKET NO 1601006026 SHORT CASE A 51 year old male gentlemen resident of Miryalaguda, farmer by occupation, presented with a chief complaints of    Fever since 10 days   Cough with sputum since 10 days   Shortness of breath since 7 days  History of present illness Patient was apparently asymptomatic 10 days back then he developed  Fever which was insidious in onset, associated with chills and rigors with diurnal variation which was more during the night and was relieved on medication  He then developed Cough with expectoration which is gradually progressive more during the nights followed a similar diurnal pattern.It aggrevated during exposure to colder climates.The sputum was scanty and yellow in color, non foul smelling Cough was associated with Chest pain which was non radiating in nature and aggrevated on lying down, relieved on sitting upright  He later developed gradually Dyspnea which went on to interfere his daily activities( MMRC grade 3/4) No history of wheeze, hemo
Read more

55 year old male with abdominal discomfort since 3days, involuntary movements 1episode since 1 day

Image
​ This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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.     55 year old male, Resident of miryalaguda came to casualty  with chief complaints of     •Abdominal discomfort since 3 days     •Involuntary movements 1episode yesterday night followed by loss of conscio
Read more
​A 36 Old Male, Cement factory worker by occupation came to the opd with chief complaints of  Abdominal pain since 5days  Right loin pain since 5 days  Vomitings since 5 days  HISTORY OF PRESENTING ILLNESS  Patient was apparently asymptomatic one year ago then he developed pain in abdomen one year ago, later he went to the local hotshot diagnoses to have right renal calculi for which he took treatment and got cured  Then he developed pain in abdomen 5days ago, which is sudden in onset, gradually progressive, aggressive on performing daily chores, nights for which he went to local RMP for treatment and got cured  The next day patient developed,Right loin pain since, which is colicky type, sudden in onset, gradually progressive , radiating to right groin  Right loin pain was associated with Vomitings 2-3episodes / day , Non bilious, Content -food particles, Non projectile  Loose stools , 3times / day , clay colored, non foul smelling , Reduced urine output less than 200ml /day and abdomi
Read more