42/M with pain abdomen

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. This E log book also reflects my patient-centered online learning portfolio.


Case history:

42/M came with c/o pain abdomen since 6months and lower backache since 1month. 

History of present illness:

Patient was apparently asymptomatic 6months back then he developed right upper abdomen pain which was insidious in onset, gradually progressive, dull aching type, non radiating with no aggravating and relieving factors. 

H/o fever with chills + since 10days. 
H/o burning micturition since 6 days 
No H/o weight loss and loss of appetite, trauma, nausea, vomiting, constipation. 

In August 2022, patient had complaints of pain abdomen and H/o jaundice for which he got his LFT done which showed increased bilirubin levels. He used herbal medication. As the symptoms did not subside he USG done showing GB stones. And he went to Govt hospital for endoscopy which reported no GB stones. Then after few days his platelet count had gone down for which he was put on some medication. He was asymptomatic afterwards. He again had symptoms of pain abdomen associated with belching, fever (on & off), and got admitted in this hospital. 

Past history:
N/k/c/o HTN, DM, CVA, CAD, TB, thyroid. 

Personal history:
Diet: mixed
Appetite: decreased
Sleep : adequate
Bowel and bladder movements:regular
Addictions: alcoholic since 20yrs. 


Family history :
  Not significant 

General examination:
Patient is consious, coherent, cooperative.
No signs of icterus, pallor,clubbing, lymphadenopathy, edema.

 Vitals: 
Temp: 98.6 F
PR: 84 bpm
RR: 20 cpm
Grbs: 115 mg/dl
Spo2: 98%


Systemic examination
 Per Abdomen 
Inspection:
Skin - smooth 
Shape - flat
Umbilicus - normal
Abdominal wall movements - present
No visible pulsations and peristaltic movements seen. 

Palpation:
Tenderness - mild
No rise of temperature
No organomegaly

Percussion: 
Tympanic note heard.

Auscultation :
Bowel sounds heard
No bruit. 

CVS - S1, S2 heard, no murmurs.
CNS - NFND 
RS - BAE present, NVBS heard 


USG: (25/5/23)



Reticulocyte count -1%
Sr. Iron - 69
Serology - negative
APTT - 39sec
BT - 2min 30sec
CT - 5 min

Psychiatry referral was taken i/v/o alcohol dependence and was advised with T. Oxazepam, Inj. Thiamine, Inj. Lorazepam, nicotine gums. 

Gastroenterology refferal was taken



Diagnosis:
Calculous cholecystitis 

Treatment: 
Inj. Taxim 1g IV/BD
Inj. Metrogyl 500mg IV/TID
Inj. Amikacin 500mg IV/OD
Inj. Vit K 1amp IM/OD
Inj. Pan 40mg IV/OD 
Inj. Vitcofol 3ml IM/OD 
Cap. Rifagut 550mg/BD
T. Orofer XT PO/BD
T. Udiliv 300mg PO/TID
T. Hifenac PO/SOS
T. MVT PO/OD 
T. PCM 650mg PO/SOS



Comments

Post a Comment

Popular posts from this blog

75 yr old with sob and cough

Image
This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input. This E-blog also reflects my patient's centred online learning portfolio. I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. Case Discussion.  75 year old male, resident of Suryapet came to OPD with chief complaints of cough since 2 months and breathlessness since 1 month and Pedal edema since 15 days. History of presenting illness. Patient was apparently asymptomatic 2 years ago, later he developed SOB...
Read more

Internship Learning experience in medicine posting

Here, I have explained all the things that I've learnt and did in my General Medicine internship postings during 2023. Cases :   https://prathyushasingam.blogspot.com/2023/05/42m-calculous-cholecystitis.html http://prathyushasingam.blogspot.com/2023/05/55f-with-left-hemiparesis.html https://prathyushasingam.blogspot.com/2023/05/35m-with-pedal-edema-and-sob.html https://prathyushasingam.blogspot.com/2023/04/67f-with-sob-decreased-urine-output.html https://prathyushasingam.blogspot.com/2023/05/raju-ward-case.html   Procedures : - Inserted Ryle's tube under the guidance of  Dr. Vivek for an AMC case. - inserted Foley's catheter and also did the removal of Foley's catheter for different patients in ICU.  - Assisted 2 lumbar puncture procedures.  ICU/AMC duties : - Assisted 1 central line in ICU case and 1 central line for AMC case under the guidance of Dr. Venkat, Dr. Nithin.  - Assisted lumbar puncture for 2 ICU cases.  Ward duties : - guided my co-intern...
Read more