Akshara kruthi 40
Hi,I am G.Akshara kruthi 5th sem medical student.This is an online elog book to discuss our patients 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 problems with collective current best evidence based inputs.This E-log book reflects my patient centered online learning portfolia
A 50 year old male , maths lecturer by occupation, resident of nalgonda came to OPD with chief complaints of
1. Abdominal pain since 4days.
2. Shortness of breath since 3days.
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 10years ago , then he developed gastric problem whenever he takes alcohol for which he is using omeprazole and rabiprazole . He vomits wantedly the next day morning he took alcohol every time. 4days back he developed upper abdominal pain which was gradual in onset and progressive with abdominal distension .
HISTORY OF PAST ILLNESS
Known case of Hypertension since 4years
Not a known case of DM, asthma, TB, Epilepsy.
PERSONAL HISTORY
Marital status : Married
Occupation : Maths lecturer
Diet : Mixed
Appetite: Normal
Bowels : Regular
Micturition : Normal
He has no known allergies
Addictions
Alcohol : Occasionally since 20 years(90ml/180 ml/day)
But he is taking alcohol frequently since 15 to 20 days.
Tobacco : Smoking since 20years (8/day)
TREATMENT HISTORY
He is taking Tab. Angiosart(telmisartan+ hydrochlorothiazide) for HTN since 4years.
Tab. Omeprazole and Tab. Rabiprazole for gastric problem since 10years.
FAMILY HISTORY
His brother also had gastric problem since 10 years.
GENERAL EXAMINATION
Patient is conscious, coherent , cooperative and examined in a well lit room.
Moderately built and nourished.
VITALS
Pulse Rate: 101/min
Blood pressure: 130/90 mmHg
Respiratory rate: 18/ min
Temperature : 98.6°F
Spo2 : 99%
GRBS : 155mg/dl
PHYSICAL EXAMINATION
Pallor : present
Icterus : absent
Cyanosis : absent
Clubbing of fingers and toes : absent
Lymphadenopathy : absent
Edema : absent
Malnutrition : absent
Dehydration : absent
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
S1 and S2 are heard
No thrills
No murmurs
RESPIRATORY SYSTEM
Dyspnea : present
No wheezing
Trachea : central
Vesicular breath sounds : Normal
PER ABDOMEN
Shape : Distended
Tenderness : diffuse type
No palpable mass
Hernial orifices : Normal
No free fluid
No bruits
Bowel sounds : present
CENTRAL NERVOUS SYSTEM
Conscious
Speech : Normal
No signs of meningeal irritation
Cranial nerves : intact
Motor system : Normal
Sensory system : Normal
Reflexes : Normal
INVESTIGATIONS
18/7/22
ECG
PROVISIONAL DIAGNOSIS
Acute pancreatitis secondary to alcohol.
TREATMENT
OVF(RL & NS) 150ml/hr
INJ.PANTOP 40mg/IV/OD
INJ.ZOFER 4mg/IV/SOS
INJ.TRAMADOL 1amp in 100ml IV/BD
INJ.THIAMINE 200mg in 100ml NS
NBM till further orders
Ryle's tube aspiration 4the hourly
Abdominal girth measurement daily
Monitor vitals 4th hourly
Strict I/O charting
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