General medicine final exam short case

 This is online E log book to discuss our patients de- identified health data shared after taking his or her guardian's signed informed consent hear we discuss our individual patients problems through a 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 also reflex my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

Date of admission: 07/02/2022

CHIEF COMPLAINTS:

A 27 year old male patient electrician by occupation presented to the OPD with chief complaints of pain in stomach and vomitings since 3 months.


HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 3 months back, when he had a trauma where his relatives had beaten him up with a stick at the left hypochondrium region due to which he developed abdominal pain associated with vomiting. The pain subsided on taking medications.

After a few days he again developed pain abdomen at the left hypochondrium region and pain radiating to back for which he went to hospital where he underwent treatment but the symptoms didn't subside.

So he went to other hospital where he took treatment..he was tested covid positive in the middle of the treatment ,so he went to home isolation .

After few days he underwent the treatment after testing covid negative, the symptoms were subsided then.

Then after he again developed the pain since 3 days before he was presented to our hospital with c/o of abdominal pain(hypochondrium region) which is radiating to his back.

The pain is aggrevated while walking, sleeping after a prolonged duration of sitting and relieved when he bends forward.

Patient complains of pain after eating.


PAST HISTORY :- 

No history of diabetes/hypertension/asthma/epilepsy

No previous surgical history 

PERSONAL HISTORY:

Diet : mixed 

Appetite : decreased since 10 days 

Sleep : inadequate 

Bowel & bladder : irregular since 3 days

Addictions :- history of alcohol intake since 4 years consumes 360ml per day, he stopped consuming since 4months.

Regular usage of khaini since 4 years.


FAMILY HISTORY : 

No relevant family history


GENERAL EXAMINATION : 

Patient is conscious, coherent, cooperative and thin built.

No pallor , Icterus,clubbing, cyanosis ,edema.


VITALS :

Temp- Afebrile 

Bp-100/80 mm hg

Pr- 84bpm

Rr-16cpm

Spo2- 99% on RA

Grbs : 102


SYSTEMIC EXAMINATION : 

Respiratory system- bilateral air entry present 

No dyspnea

No wheeze

Position of trachea- central


ABDOMEN-

Tenderness - present at hypochondrium region

Shape of abdomen- scaphoid

Spleen not palpable

Bowel sounds are present


CNS:

Level of consciousness- conscious

Speech - normal

No neck stiffness


CVS:

S1 and S2 are heard.


INVESTIGATIONS:



Hemogram:

Hb=10.5 gm/dl

PCV=#32.5

Liver function test:

Total bilirubin- 0.48mg/dl

Direct bilirubin- 0.17mg/dl

SGOT=13 IU/L

SGPT=14 IU/L

Alkaline phosphatase= # 291IU/L

Total proteins- #5.9gm/dl

Albumin # 2.9gm/dl

A/G ratio =0.98

Serum amylase=292

CRP POSTIVE 2.4mg/dl










PROVISIONAL DIAGNOSIS:

Chronic pancreatitis with pseudocyst


TREATMENT:

1. IVF NS/RL - 75ml/hr

2. Inj Tramadol 100ml IV/TID

3. Inj Pantop 40mg IV/OD

4. Inj.zofer 4mg IV/SOS







Comments

Post a Comment

Popular posts from this blog

GM Case history-1

Image
 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. 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.    Date of admission: 09-08-2021 A 56- year- old woman presented to the OPD with chief complaints of fever, decreased urine output since 3 months and  breathlessness from the past 3 days. HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 5 years back, then had fever which was insidious and associated with chills, vomiting and pain in the loin for which she went to outside hospital where she was diagnosed with kidney disease, from then she was on medication. 7 months back she stopped medication for 1 month, then after that she developed shortness of breath for which she went to a local
Read more

General medicine case-6

Image
 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. 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 patients 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: 15/10/21 A 50 year old female came to the OPD with chief complaints of lower backache, decreased urine output, shortness of breath and fever since 4 days. History of present illness: The patient was apparently asymptomatic 4 days back when she noticed a pain in the lower back and decreased urine output and shortness of breath. History of past illness: The patient is a known case of hypertension since 7 years. Not a known case of diabetes,asthma, epilepsy, tuber
Read more

Prefinal assessment

Image
 1) Define heart failure. Etiology and clinical features of heart failure? How do we diagnose heart failure clinically. Physical examination and various modalities used in diagnosis of heart failure. Write a brief note of treatment of heart failure. 2) Define cirrhosis of liver. Etiopathogenesis of cirrhosis. Write a brief note on clinical features, diagnosis and treatment of cirrhosis of liver. 3) Elaborate on clinical features and diagnostic modalities in diagnosis of renal calculi. 4) Etiology of pleural effusion. Diagnostic criteria of pleural effusion. 5) Diagnosis and treatment of dengue fever. 6) Clinical features and diagnosis of peptic ulcer disease.  7)Treatment of acute pyelonephritis. 8) Treatment of abdominal tuberculosis. 9) Etiology and treatment of pneumonia. 10) Complications of dialysis. 11) Ascitic fluid analysis. 12) Proton pump inhibitors. 13) Afterload reducing agents in heart failure. 14) Treatment of urinary tract infection. 15) Differential diagnosis of fever w
Read more