30yrs old male with epigastric pain

 Sahithi.N

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


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








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