Bhavya's Elog

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

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


Here is a case I have seen: 

       

 

A 45 year old male,labourer by occupation and resident of  nalgonda came with chief complaints of 
Abdominal pain and vomitings since 1day.

 HOPI:
     Patient was apparently asymptomatic 1day back then developed abdominal pain since morning,which was sudden in onset,gradually progressive,radiating to epigastrium (diffuse),not relieved on medication.
He has vomitings since 1day,which is bilious in content.
  
NEGATIVE HISTORY:
 There is no history of 
      Fever
      Shortness of breath
      Cough
      Heart burn
      Abdominal distension
       Dyshagia
       Conspitaion
       Diarrhea
       Anorexia
       Weight loss
       Hematemesis
       Melena
       Jaundice
       Flatulence

PAST HISTORY:
       He is k/c/o acute pancreatitis 11months back for which he was admitted and treated.
   Not a k/c/o DM/HTN/Asthma/Epilepsy/CAD/CVA.

PERSONAL HISTORY:
      Diet: Mixed
      Sleep:Adequate
      Appetite: Lost
      Bowel:Regular
      Bladder: Burning micturition
      Addictions: Alcohol since 20years,daily 2 bottles of toddy,stopped for 2months after first admission.Last drink: 2toddy bottles 5days back.
                           Smoking since 20years,1 pack per day.Last smoke:20beedis 5days back.
GENERAL EXAMINATION:
     Patient is conscious,coherent,cooperative,Thin built,moderately nourished.
     Pallor: Negative
     Icterus:Negative
     No clubbing,cyanosis,lympadenopathy,edema.
Vitals: Bp:100/60mmHg 
            Pr:56bpm regular in rythm,normal in volume,consistency:normal.
            Afebrile
           Rr:15cpm
SYSTEMIC EXAMINATION: 
GIT:
   Inspection:
         Abdomen: Shape: Normal
         Umbilicus: Inverted
         No scars,sinuses,pulsations,visible             peristalsis,superficial veins,pigmentation.
         Hernial orifices are free
   Palpation:
        No local rise of temperature
        No tenderness
        No organomegaly
        Abdomen is soft.
        Liver span: 10cms

CVS: S1,S2 heard.No murmurs heard.
 RESPIRATORY SYSTEM: NVBS heard,BAE (+)
CNS: Intact

   DIAGNOSIS:
         ACUTE ON CHRONIC PANCREATITIS
  TREATMENT:
      1.IVF -NS,DNS,2RL @100ml/hr
      2.Inj.PAN 40mg IV BD
      3.Inj.Zofer 4mg IV TID
      4.Inj.Thiamine 1Amp in 100ml NS/IV/TID
      5.Inj.Tramadol 50mg in 100ml NS/IV/BD
      6.NBM till further orders
      7.BP/PR/Temp hourly.
      8. GRBS 4th hrly
      9.Inj.Optineuron 1Amp in 1DNS IV OD
      10.I/O charting.
         
 

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