A 32 year old male patient who is a resident of mothkur came to the OPD with chief complaints of pain abdomen since 3 days, 1 episode of vomiting 2 days back



History of present illness:

Patient was asymptomatic 4 years back then developed pain abdomen which was relieved by medication.


Then 3 days back , he developed pain abdomen in epigastrium, left hypogastrium, and lumbar region along with 1 episode of vomiting which is green in color (bilious).

He complains of loss of appetite since 2days.

He complains of constipation since 2 days.


History of past illness:

N/K/C/O Hypertension, diabetes mellitus, epilepsy , asthma ,CAD Tuberculosis.

No relevant surgical history.

PERSONAL HISTORY :

Married

Diet - Mixed

Appetite - decreased

Bowel and bladder movements - Irregular

Sleep - adequate

Addictions - chronic alcoholic.


FAMILY HISTORY :

No significant family history.



GENERAL PHYSICAL EXAMINATION :

Patient is Conscious,Coherent, Not co operative. Moderately built, moderately nourished.
Well oriented to time,place, person.


Pallor -

Icterus +

Cyanosis -

Clubbing -

Lymphadenopathy -

Edema -



VITALS

BP - 110/80

PR - 72 bpm

RR - 16cpm

TEMP - Afebrile

SPO2 : 96% on room air.

GRBS : 88 mg %




SYSTEMIC EXAMINATION :


CVS : S1 S2 heard ,no murmurs heard

RS : BAE + , NVBS +

CNS : No focal neurological deficits.

PA :  Soft, Tender.

INVESTIGATIONS : 










X RAY : 








ULTRA SOUND REPORT : 










PROVISIONAL DIAGNOSIS :

Acute pancreatitis.



TREATMENT : 

INJ PAN 40 mg /IV /OD

INJ ZOFER 4 mg /IV / SOS 

INJ THIAMINE  1 AMP in 100ml NS  IV / TID 

INJ TRAMADOL 1 AMP in 100ml NS / IV / SOS

 IVF - NS ,DNS,RL  at 100 ml / hr .





Comments

Post a Comment

Popular posts from this blog

Image
 A 58 year old male, labourer by occupation, came to the OPD with the chief complaints of Shortness of breath since 30 days,which was worsened 1 day back(19/02/22), chest pain since 30 days ,facial puffiness since 30 days History of Presenting illness -   Patient was apparently asymptomatic 3 years ago then developed giddiness,  for which he went to a local hospital and was diagnosed as Hypertensive, for which he is taking T. Nicardia 10mg, T. Arkamine 0.1mg sos. Then 2 years back he  developed B/L pedal edema,  which progressed gradually to knees and  diagnosed with renal failure, started dialysis weekly twice. Since 4 months he developed left upper limb swelling and swelling at chest region,both of  which got  progressed to current size.  Back pain since 2 months, which got subsided on medication (T. Ultracet).  30 days back - he developed shortness of breath ,Grade II-III  which progressed to Grade IV since 30 days associated with orthopnea . Whereas from 4 days he developed right u
Read more

50 M with Abdominal distension, shortness of breath since 1 week

Image
This is a case of 50 year old male who is government servant came to the opd with chief complaints of Abdominal distension with pain abdomen since 1 week Loss of appetite since 1 week Shortness of breath since 1 week B/L lower limb swelling since 5 days  Decreased urine output since 5 days Reddish yellowish discoloration of urine since 5 days  Patient was apparently asymptomatic one week back then he noticed abdomeninal distention which was diffuse associated with abdominal pain( squeezing type ) not associated with vomotings , loose stools ,fever Aggravated with food intake  Complaints of bilateral pedal edema which is pitting type gradually progressive , extending from ankle to knee joint  C/o decreased urine output and yellowish discolouration of urine since 5 days not associated with fever with chills and burning miturition , frothing of urine  No h/o chest pain , palpitations , excessive sweating .  Complaints of shortness of breath with grade II which is decreased in supine posi
Read more

1801006077 SHORT CASE

Image
 A 40 year old female patient ,hotel owner, resident of Narketpally came with chief complaints of Increased heartbeat since 6 months Breathlessness since 6 months HISTORY OF PRESENT ILLNESS : Patient was apparently asymptomatic 6 months back then she developed palpitations which were sudden in  onset, gradually progressive and develops under stress, heavy work. It lasts for 2 to 3 min and relives on rest . Since the last 2 to 3 months she complains of increased frequency and intensity of palpitations. She also complains of breathlessness ( shortness of breath) since 6 months and it was gradually progressive from grade 1 (6 months back)to 3 (presently)and it relieves on rest. Patient also has fainting attacks , headache when there is delay in food intake or prolonged standing and it gets relieved on taking rest or food. PAST HISTORY Not a known case of Diabetes, Hypertension, Asthma, Tuberculosis,Epilepsy, Thyroid disorders. Has acidity from past 15 years. She develops burning sensation
Read more