gen medicine case

 Aksharakruthi  8 th sem 

This elog depicts the patient -centered approach to learning . This is an online E log book recorded to discuss and comprehend our patients de-identified health data shared , after taking his /her /guardians signed informed consent . This elog also reflects patients centered learning portfolio.


40 yr old male patient who is daily wage labourer by occupation came to OPD with

 CHIEF COMPLAINTS :

of pain abdomen since 5 days associated with fever since 2 days .


HISTORY OF PRESENT ILLNESS 


Patient was apparently asymptomatic 5 days ago then he developed pain which is insidious in onset and gradually progressive which is diffuse , squeezing type and radiating to back .
Pain is relieved on medication .
No C/O of vomitings , loose stools , burning micturition ,cough,cold , chest pain , SOB 

.
HISTORY OF PAST ILLNESS

N/K/C/O TB , hypertension, diabetes, Asthma, epilepsy , CAD, thyroid disorders .

PERSONAL HISTORY 
Diet - mixed 
Appetite- normal
Bowel and bladder -regular
Sleep - adequate
Addictions - regular alcohol intake of 250 ml per day since 20 yrs .
No food allergies and drug allergies


GENERAL EXAMINATION

Pallor - yes 
Edema -absent 
Clubbing - absent 
Lymphadenopathy - absent 
Icterus - absent 

 
Vitals - 

Temperature - 100.1F
BP-85/60
Spo2- 98%
RR-20pm
PR- 100/min
 SYSTEMIC EXAMINATION

PER ABDOMINAL EXAMINATION:

Patient exposed from nipple to mid thigh and examined in supine position 

INSPECTION: 


Shape:Distended flanks full 

Umbilicus:inverted,vertically drawn down

Skin over the abdomen is shiny

No visible peristalsis,



Palpation:

On superficial Palpation 


All inspectory findings are confirmed 

Tenderness+

,diffuse all quadrants

No Rebound tenderness 

No guarding,rigidity

Percussion



Shifting dullness absent 

fluid thrill absent 

Liver span-12cm

Percussion of spleen : dullness in 9th inter coastal space of anterior axillary line 

Auscultation 

Bowel sounds+


No arterial bruit,



RESPIRATORY SYSTEM 

Inspection 

Shape of chest:Bilaterally symmetrical,Elliptical in shape

No visible chest deformities

Abdomino thoracic respiration,No irregular respiration

No tracheal shift

No dropping of shoulders, on both sides,no sinuses,scars,engorged veins



Palpation
:inspectory findings confirmed by Palpation 


Chest movements -normal



Percussion:

Resonant note heard over all areas 

Auscultation: 

Norma vesicular breath sounds

, breath sounds normal 



CARDIOVASCULAR SYSTEM:

Inspection:precordium normal,apex beat :5th ICS half inch medial to mid clavicular line

Palpation:inspectory findings confirmed,No thrills or parasternal heave



Auscultation: S1S2+,no murmurs



CNS:
patient is arousable 

No signs of meningitis 

cranial nerves intact,motor and sensory examination normal


No cerebellar or meningeal signs


Reflexes
Knee 3+. 3+

Reflexes Rt. Lt 
Biceps 3+. 3+
Triceps 3+. 3+
Supinator 2+. 2+
Knee 3+. 3+

              Right. Left 
UL. 2/5. 3/5
LL. 2/5. 3/5



PROVISIONAL DIAGNOSIS 

 Acute pancreatitis ( non necrotizing type) peripancreatic fluid collection.
Investigations:



















TREATMENT
1 .IV fluids 125ml/hr 
2.injec.zoffer 4 mg IV
3.inj Tramadol 1 ampoul in 100ml NS
4.inj piptaz 4 to 5 mg 
5. Inj pan 40 mg IV
6.inj neomol 1gm IV

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