INTERN'S E LOG



"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 and your valuable inputs on the comment box is welcome."

CASE

      A 22 years old male patient  who is a student and resident of Itukulapadu came with the chief complaints of pain abdomen and vomittings since 1 day, and did not pass stools today.

HISTORY OF PRESENTAT ILLNESS -
Patient was apparently assymptomatic 1 day back and then developed pain abdomen in the epigastrium, right hypochondrium and umblicus; colicky type. No aggravarting and relieving factors.
Complaints of 1 episode of vomitting yesterday night, watery contains food particles; non - bilious and non - blood tinged.
No h/o loose stools,SOB, pedal edema, chest pain
No h/o decresed urine output

HISTORY OF PAST ILLNESS -
Not a known case of DM, HTN, TB, asthma , epilepsy. No similar complaints In the past. 

PERSONAL HISTORY - 
Appetite - lost
Diet - mixed
Bowel movement - constipation since 1 day
Micturition - normal
Chronic alchoholic since 2 years
No known drug and food allergies

FAMILY HISTORY -
not significant

PHYSICAL EXAMINATION
A) GENERAL EXAMINATION -
Patient is C/C/C 
Pallor - absent 
Icterus - present 
Cyanosis - absent 
Clubbing - absent 
Lymphadenopathy - absent 
Oedema - absent 
Malnutrition - absent 
Dehydration - absent 
PR - 94/ min
BP - 140/80 mmHg
Spo2 - 98%
GRBS - 129 mg %

SYSTEMIC EXAMINATION -
CVS - S1 ,S2 heard . No thrills and murmurs
RS- NVBS , B/L airway present
        Position of trachea - central
ABDOMEN - 
 Shape of abdomen - scaphoid
Tenderness - present  ; epigastrium and right hypochondrium , umblicus and B/ L lumbar areas. Guarding and rigidity - present 
Bowel sounds - absent
CNS - intact
 
PROVISIONAL DIAGNOSIS - 
 Acute Pancreatitis
 
Investigations - 
HCV
LFT 
RFT -
 urea levels : decreased from 27 on 13/6/20  to  on 23 on 16/6/20
creatinine levels : decreased from 0.7 on  13/6/20 to 0.4 on 16/6/20
uric acid levels - increased from 2.5 on 13/6/20 to 3.3   on 16/6/20
Urinec c/s 
blood c/s
Serum amylase - decreased from 335 on 12/6/20  to 52 on 16/6/20
Serum lipase - decreased from 100 on 12/6/20 to 60 on 17/6/20
CBP -
total count was decreased from 15000 on 12/6/20 to 10900 on 18/6/20
Haemogram 
serum electrolytes -
Na : 136 mEq/L
K :  3.8 mEq/L
Cl : 99 mEq/L
ABG -
pH - 7.42
pCO2 - 30.1mmHg
pO2 - 87.1 mmHg
HCO3 - 19.3mmol/L
BEB -  -4.2mmol/l
BEecf - -4.3moml/l
TCO2- 41.9 VOL
O2sat - 96.4%
O2 count - 8.7 vol%


TREATMENT - 
1) IVF  - NS - bolus  -10
               Rl
               DNS
At 125 ml / hr
2) inj pan - 40 /mg/ iv/BD
3)inj zofer - 4mg /IV /TID
4)inj tramadol - 1 amp in 100 ml NS/IV/BD
5) inj thiamine -  1 amp in 100 ml NS/ IV / BD
6) strict 1/0 charting
7)  GRBS - 8th hrly charting
8)inj ceftriaxone - 1g/IV/ BD




  

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