SHRUTHI ARUKONDA 02

 GENERAL MEDICINE. 


24 July ,2021. 

Note: This is an online E Log book recorded to discuss and comprehend our patient's  de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.


            CASE REPORT 

A 26 year old male who is a car driver by profession presented with chief complaints of pain abdomen since yesterday.  

CHEIF COMPLAINTS : 

Pain abdomen since yesterday (epigastric and right and left hypochondriac pain) associated with 2 episodes of vomitings (bilious).  

HISTORY OF PRESENT ILLNESS : 

  • Patient was asymptomatic until 4 months back and consumed alcohol daily for a week, after which he developed a pain abdomen associated with vomitings for which he was admitted in the hospital for a week. 
  • Diagnosed with acute pancreatitis.
  • Was under medication and the pain has subsided, due which he was discharged.  
  • Recently, he started consuming toddy regularly due to which he had a pain abdomen which started in the epigastric region associated with 2 episodes of vomitings which are bilious and non blood tinged.  

HISTORY OF PAST ILLNESS : 
 
N/k/c/o DM, BP, CKD, CHF, Epilepsy. 


TREATMENT HISTORY: 

Nothing significant 

PERSONAL HISTORY : 

Appetite: decreased 
Non veg: occasionally. 
Sleep: adequate 
Alcohol : toddy occasionally 
Non smoker.  

FAMILY HISTORY: 

Nothing significant.  


PHYSICAL EXAMINATION: 

GENERAL EXAMINATION:  

No signs of pallor, cyanosis, icterus, edema, lymphadenopathy. 

VITALS: 

Temp : 99 F
Pulse rate: 78/min 
Respiratory rate: 16/min
BP: 110/70
Spo2: 96%
GRBS:144mg% 


SYSTEMIC EXAMINATION: 

CVS: 

Thrills: no  
Cardiac sounds : S1+ S2+ 
Cardiac murmurs : no 

RESPIRATORY SYSTEM: 

Dyspnoea: no 
Wheeze: no 
Position of trachea: central 
Breath sounds: vesicular 

ABDOMEN: 

Shape : obese 
Palpable mass: no
Liver and spleen : not palpable 
Free fluid: no 
Bowel sounds : yes 

CENTRAL NERVOUS SYSTEM: 

Normal.  

INVESTIGATIONS : 

1. Ultrasound. : 





2. 2D ECHO: 




3. ECG: 



4. X- RAY: 


5: serum amylase: 
















Temperature chart : 




Clinical images: 








Provisional diagnosis: acute pancreatitis.  





























Comments

Post a Comment

Popular posts from this blog

SHRUTHI ARUKONDA 02

           GENERAL MEDICINE ASSIGNMENT                           Shruthi Arukonda 02   (3rd sem)                           Monthly  online assignment   I have been given the following assignment in an attempt to read,  comprehend, analyze, reflect upon and discuss captured patient centered data. This is the link of the questions asked regarding the cases: https://medicinedepartment.blogspot.com/2021/06/medicine-department-paper-for-june-2021.html?m=1 Below are my answers to the Medicine Assignment based on my comprehension of the cases.  QUESTION ONE:  1. PULMONOLOGY CASE:    Case details :  https://amitsharma1996.blogspot.com/2021/05/medicine-assignment-may-2021.html Case review :  https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html            Evolution of symptomatology has been very well explained with a proper timeline for clear understanding.  The mechanism of action has also been depicted well  2.NEUROLOGY CASE:A case details:   https
Read more

SHRUTHI 02

Image
  Date of admission :  A 55 year old male resident of Nalgonda presented to the causality with lower back ache and radiating pain to the left leg  since 3 weeks  HISTORY OF PRESENT ILLNESS : Patient was apparently asymptomatic until 3 weeks ago after which he developed lower back ache which is sudden in onset, non progressive, aggravates on movement, relives on rest.  History of trauma (slip and fall from stairs) 3 weeks ago  The patient was taken to the local hospital where he was found to have L5 burst fracture on CT pelvis.  No history of lifting heavy weights, fever, burning micturition,  PAST HISTORY :  k/c/o DM T2 since last 30 years  K/c/o CAD since 2 years  N/k/c/o of HTN, epilepsy, TB, asthma.  History of  PCTA 2 years ago   TREATMENT HISTORY:  Tab. Metformin 500mg  Tab . Roglibose 0.2mg  Tab. glimidipine 2mg  PERSONAL HISTORY :  sleep : adequate  Bowel and bladder : regular  Appetite : normal  Addictions: alcohol occasionally  Allergies : none  GENERAL EXAMINATION:   Bilatera
Read more

SHRUTHI ARUKONDA 02

      GENERAL MEDICINE            SHRUTHI ARUKONDA 02 ( 3rd sem)          BIMONTHLY ASSIGNMENT- August  I have been given the following assignment in an attempt to read,  comprehend, analyze, reflect upon and discuss captured patient centered data This is the link of the questions asked regarding the cases: https://medicinedepartment.blogspot.com/2021/08/medicine-paper-for-aug-2021-bimonthly.html?m=1 Below are my answers to the Medicine Assignment based on my comprehension of the cases. QUESTION ONE :  Long case:  The history taking was exceptionally good  The exacerbating factors were very well depicted  The details of his joint pains has been explained well.  The general and systemic examination were very explicit.  The various differential diagnosis approach was very depicted along with proper explanations .  Short case:  The history of present illness was taken down exceptionally well  All the alleviating and exacerbating factors were very well mentioned.  The personal history is v
Read more