30yrs old male with epigastric pain

 Sahithi.N

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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 diagnosis and treatment 

Case history:

Complaints- 

c/o pain over epigastric region since 8:45pm yesterday.

HOPI- 

Pt was apparently asymptomatic 1 months back then developed pain over epigastric region, aggravated with spicy food intake and relieved on medication. 

Had similar complaints 3 days ago, relieved with medication. 

Now patient presented with pain over epigastric region since 8:45 pm, localised over the region, non radiating, tenderness present.

No SOB, palpitations, orthopnea, PND.

No c/o fever, vomitings, diarrhea.

Past history:

Not a k/c/o HTN, DM, thyroid disorders,epilepsy, CVA, asthma.

General examination-

Patient is C/C/C

Temp- 98.2F

BP-130/80mmhg

PR- 96 bpm

RR- 18cpm

GRBS- 104 mg/dl

SYSTEMIC EXAMINATION 

PA:

Inspection:

Round, with distention

Umbilicus: Inverted

No visible pulsation,peristalsis, dilated veins and localized swellings.

Palpation: 

Soft, distended,tenderness present in epigastric region

No signs of organomegally

Percussion: 

No fluid thrill, shifting dullness absent

Auscultation: 

Bowel sounds heard 2-3/ minute

CVS:

Inspection:

There are no chest wall abnormalities 

The position of the trachea is central. 

Apical impulse is not observed. 

There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses. 

Palpation:

Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line 

Position of trachea was central 

Auscultation: 

S1 and S2 were heard 

There were no added sounds / murmurs. 

RESPIRATORY SYSTEM:

Bilateral air entry is present 

Normal vesicular breath sounds are heard. 

CNS:

HIGHER MENTAL FUNCTIONS- 

Normal

Memory intact

CRANIAL NERVES :Normal

SENSORY EXAMINATION

Normal sensations felt in all dermatomes

MOTOR EXAMINATION

Normal tone in upper and lower limb

Normal power in upper and lower limb

Normal gait

REFLEXES

Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited

CEREBELLAR FUNCTION

Normal function

No meningeal signs were elicited

Diagnosis- acute cholecystitis with cholelithiasis

Investigations:

Treatment-

1. Normal diet allowed 
2. Plenty of oral fluids
3. Inj. Pan 40mg PO BD
4. Inj. Tramadol 1amp in 100ml NS IV/ SOS
5. Inj. Thiamine 200mg PO/TID
6. Tab. TAXIM 200 mg PO/BD
7. TAB. METROGYL 400mg PO/TID
8. Monitor vitals 4th hourly 
9. Inform SOS

29.5.2023

S  

C/O yellowish discolouration of urine

C/O R hypochondriac region pain (tenderness +)

No fever spikes

Stools not passed

 

O: 

Patient is conscious coherent and cooperative 

No pallor, icterus , clubbing, cyanosis, lymphadenopathy , pedal edema

Vitals : 

BP- 120/80 mmhg

PR -96bpm 

RR-18cpm

Spo2-95% at room air 

Temperature - 98.4F

GRBS at 8:00am 107 mg/dl

CVS: S1,S2 heard ,no Murmurs, jvp not raised 

RS:BAE,no added sounds ,NVBS, 

P/A: soft, distended, tenderness present 

CNS:NFND

A: 

Acute pancreatitis

P:

 1. NBM till further orders.

 2. IVF- NS, RL, DNS at 100ml/hr

 3. Inj. Pan 40mg IV BD

 4. Inj. Tramadol 1amp in 100ml NS IV/ BD

 5. Inj. Thiamine 200mg in 100 ml NS IV/ TID

 6. Monitor vitals 4th hourly

 7. I/O charting

 8. GRBS 2nd hourly

3.6.2023

S:  

No fresh complaints

 

O: 

Patient is conscious coherent and cooperative 

Icterus present

No pallor, clubbing, cyanosis, lymphadenopathy , pedal edema

Grbs- 98mg/dl

Vitals : 

BP- 130/90 mmhg

PR -59bpm 

RR-18cpm

Temperature -98.6F

CVS: s1,s2 heard ,no Murmurs

RS:BAE ,NVBS, 

P/A: soft, non tender, no organomegaly

A: 

Acute cholecystitis with cholelithiasis

P:

 1. Normal diet allowed 

 2. Plenty of oral fluids

 3. Inj. Pan 40mg PO BD

 4. Inj. Tramadol 1amp in 100ml NS IV/ SOS

 5. Inj. Thiamine 200mg PO/TID

 6. Tab. TAXIM 200 mg PO/BD

 7. TAB. METROGYL 400mg PO/TID

 8. Monitor vitals 4th hourly 

 9. Inform SOS

SUMMARY

Diagnosis- acute cholecystitis with cholelithiasis

Complaints- 

c/o pain over epigastric region since 8:45pm yesterday.

HOPI- 

Pt was apparently asymptomatic 1 months back then developed pain over epigastric region, aggravated with spicy food intake and relieved on medication. 

Had similar complaints 3 days ago, relieved with medication. 

Now patient presented with pain over epigastric region since 8:45 pm, localised over the region, non radiating, tenderness present.

No SOB, palpitations, orthopnea, PND.

No c/o fever, vomitings, diarrhea.

Past history:

Not a k/c/o HTN, DM, thyroid disorders,epilepsy, CVA, asthma.

General examination-

Patient is C/C/C

BP-130/80mmhg

PR- 96 bpm

RR- 18cpm

GRBS- 104 mg/dl

Temp- 98.2F

SYSTEMIC EXAMINATION 

CVS- S1S2+,NO MURMURS

RS- BAE+,NVBS HEARD

P/A- SOFT,NON TENDER,BOWEL SOUNDS+

CNS- ORIENTED TO TIME,PLACE AND PERSON

Treatment-

1. Normal diet allowed 
2. Plenty of oral fluids
3. Inj. Pan 40mg PO BD
4. Inj. Tramadol 1amp in 100ml NS IV/ SOS
5. Inj. Thiamine 200mg PO/TID
6. Tab. TAXIM 200 mg PO/BD
7. TAB. METROGYL 400mg PO/TID
8. Monitor vitals 4th hourly 
9. Inform SOS

ADVICE AT DISCHARGE

Plenty of oral fluids

Tab Pan 40mg po/od/bbf

Tab thiamine 200mg po/bd

Tab taxim 200mg po/bd for 4 days

Tab metrogyl 400mg po/tid for 4 days

Review to surgery and medicine OPD after 1 week