Final GM long case

 


This is an online E- log book to discuss our patient's de- identified health data shared informed 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 comment box is welcome."

Date of admission:- February o4, 2022

Chief complaint:-

A 36 year old male patient came to OPD with chief complaints of pain in the abdomen since 45 days.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 45 days  back and then  he developed pain in the abdomen  (epigastric region) . It is associated with nausea and loss of appetite.

One month back patient visited to local hospital with similar complaints of pain in abdomen,  so he was given .I.v. fluids of pantop 40mg and buscopan and felt relief.

No history of vomitings.

No history of constipation. 

No history of jaundice.

PAST HISTORY:

No history of diabetes,  hypertension,  asthma, TB, epilepsy, thyroid disorders. 

No history of any surgeries in the past. 

No history of similar complaints in the past. 

PERSONAL HISTORY:

Appetite: low

Diet: mixed 

Sleep: inadequate 

Bowel and bladder movements: regular 

Micturition: normal

Addictions: 

 Alcohol consumption- regular

Toddy since 15 years

Whisky 250 ml once in 2 days for 1 year.

FAMILY HISTORY:

No member of the family had similar complaints. 

TREATMENT HISTORY:

Patient had not undergone any treatment prior. 

He is not allergic to any known drugs. 

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative and well oriented to time, place and person. 

There is no signs of  pallor, icterus, cyanosis, clubbing and generalised lymphadenopathy. 

VITALS:

Temperature: afebrile

Blood pressure:  110/ 80 mm Hg

Pulse rate:  90 beats / min

Respiratory rate: 20/ min

Spo2 : 97% at room temperature 

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

No thrills 

S1 and S2 sounds are heard 

No cardiac murmurs

RESPIRATORY SYSTEM:

Dyspnoea- no

No wheezing sounds 

Position of trachea- central 

Breath sounds- vesicular 

ABDOMEN:

Shape of abdomen- scaphoid 

Tenderness- no 

Palpable mass- no 

Hernial orifices- normal 

Free fluid- no 

Bruits- no 

Liver - not palpable

Spleen- not palpable

Bowel sounds- yes 

CENTRAL NERVOUS SYSTEM:

Level of consciousness: conscious 

Speech: normal 

Signs of meningeal irritation

Neck stiffness- no 

Cranial nerves- normal 

Motor system- normal 

Sensory system- normal 

CLINICAL IMAGE'S:-




INVESTIGATIONS:- 












PROVISIONAL DIAGNOSIS:

Acute pancreatitis 

TREATMENT:

1. IVF - NS/RL- 100 ml / hr

2. Inj. PAN 40 mg IV/OD

3. Inj. ZOFER 4 mg/ IV/ 

4. Inj. TRAMADOL 1 amp/ IV in 100 ml NS

5. Inj. THIAMINE 1 amp in 100 ml NS IV/ OD







Comments

Post a Comment

Popular posts from this blog

Prefinals answers

Image
2. Define cirrhosis of liver. Etiopathogenesis of cirrhosis. Write a brief note of clinical features, diagnosis and treatmentof cirrhosis of liver. 4. Etiology of pleural effusion. Diagnostic criteria of pleural effusion.  5. Diagnosis and treatment of Dengue fever.  6. Clinical features and diagnosis Peptic ulcer disease.  9. Etiology and treatment of pneumonia.  10. Complications of dialysis  11. Ascitic fluid analysis.  14. Treatment of urinary tract infection. 15.Differential diagnosis of fever with rash . 16.Insulin therapy in diabetes mellitus.  17.Antihypertensive drugs in chronic Renal failure.  18. Types of intracranial hemorrhage.
Read more

General medicine case 8

Image
  54 yrs old male patient with acute kidney injury secondary to left lower limb cellulitis December 05, 2021 54 years old male patient came with chief complaints of shortness of breath and left lower limb swelling since 5 days . H/o present illness:- Patient was apparently asymptomatic 5 days back and then he had a injury to his left leg followed by itching of leg and developed left lower limb swelling associated with shortness of breath ( grade II- III) according to NYHA  classification. No history of chest pain/palpitations. No history of chronic cough/hemoptysis In 2016 patient went to hospital  due to pedal edema where patient had ischemic encephalopathy followed by 4 sessions of dialysis was done and discharged not as any medications after that. Past history:- Patient is not a k/c/o Dm, asthma, epilepsy hypertension. Personal history: Diet-mixed  Appetite-decreased Bowel and bladder movements-regular Daily alcohol consumer 5 years back,stopped 5 years back and recently he had 100
Read more

General medicine case

Image
  This is an online elog book to discuss our patients de-identified health data shared after taking his /her/ guardian informed consent here we discuss our individual patients problems through series of input from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. Date of admission: 21 October 2021 A 60 yr old male who is a farmer by occupation came to the OPD for the dialysis diagnosed as kidney failure 1 1/2 back . He went to local hospital and was diagnosed with renal failure( serum creatinine 3mg/dl) Chief complaint: patient complains of shortness of breath, sleeplessness, swelling of limbs. HISTORY OF PRESENT ILLNESS : •Pedal edema  • Anorexia  • Fever  • Dyspepsia  •  Insomnia  • Serum creatinine levels - increased (2 mg /dl)  • Decreased urine output  Presently on dialysis on MHD  HISTORY OF PAST ILLNESS :  On dialysis since 1 and half year  K/h/o Hypertension sice 6 years  No h/o
Read more