gm case

 

Hi all. This is Mounika, a third semester medical student. 

            This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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. 

Note :This is an ongoing case and will be updated as and when the information is provided.

A 27 years male patient occupation by electrician came with chief complaints of pain abdomen since 3 months 

HISTORY OF PRESENT ILLNESS :- 

patient was apparently a symptomatic 3 months back, then he had a trauma where his relatives beaten him with stick at the left hypochondrium region and 

then he developed mild diffuse abdominal pain associated with bilious vomiting .projectile .contains food particles , then the pain subsided on taking medications 

After a few days he again developed pain abdomen at the left hypochondrium region and the pain radiating to back , then he went to government hospital where he under went treatment but the symptoms didn't subsided 

So he went to a private hospital we he took treatment but in the middle of treatment , he tested postive in the hospital , so he went to home isolation , were he approached a local  rmp for the pain abdomen and covid .

After  5 days he tested negative in mid of January  so he went back to the same private  hospitaland under went treatment and his symptoms resolved and the doctors said that there may be chances of symptoms appear again.he didn't complain of any symptoms for the next days

Then after he developed pain again he now tolerated the pain for 3 days after which he came to our hospital with the cheif complaints of pain abdomen at the hypochondrium and epigastric region which is intermittent , squeezing type of pain and the pain radiating to the back where there is the pricking type of pain and the pain radiating to the left shoulder tip 

The pain is aggreavted with walking, sleeping after a prolonged duration of sitting and  relieved when he bends forward 

Patient when complaining of pain done cect abdomen 1/12 /2021 where  the impression  is pancreatitis with pseudo cyst 

PAST HISTORY :- 

NO H/O dm, htn, asthma, epilepsy

No previous surgical history 

PERSONAL HISTORY 

diet : mixed 

Appetite : decreasd since 10 days 

Sleep : inadequate 

Bowel & bladder  : regular 

addictions :- h/0 of alcoholic intake since 5 years , regular intake of alcohol and the there is a high intake of the alcohol . he stopped the intake of alcohol 4 months back 

FAMILY HISTORY : Not significant

ON EXAMINATION : 

Patient  is conscious, coherent, cooperative.

 pallor , Icterus,clubbing, cyanosis ,  koilonychia, edema are absent

VITALS 

Temp- Afebrile 

Bp-100/80 mm hg

Pr- 84bpm

Rr-16cpm

Spo2- 99% on RA

Grbs : 102

SYSTEMIC EXAMINATION : 

RS-  bilateral air present 

Cvs-S1 S2 +

P/A - tenderness present in epigastric region and left hypochondrium 

rigidity present in the epigastric region and left hypochondrium 

no gaurding 

bowel sounds present 

CNS   NAD 

GCS - 15/15

INVESTIGATIONS :- 

HEMOGRAM 

HB 10.5 GM/DL 

TLC #10,500 

N/L/E/M/B. #135/20/#40/05/00

PCV #32.5 

MCV # 82.7 

MCHC 32.6 

RBC. #3.93 

PLT. 5.5 

CUE :- 

ALBUMIN.   NIL 

BILE SALTS AND PIGMENTS   NIL

PUS CELLS   NIL 

LFT :- 

TB  0.48 MG/DL

DB 0.17 MG/DL

SGOT 13 IU/L 

SGPT. 14 IU/L 

ALP.   # 291 IU/L

Tp.   # 5.9 gm/dl 

albumin. #2.92 gm/dl 

A/G RATIO. 0.98 

SERUM AMYLASE. 292 

SEROLGY. NEGATIVE 

CRP POSITIVE  2.4 MG/DL

TREATMENT GIVEN 

1) IVF NS /RL @75 ml / hr 

2) inj Tramadol 100 ml IV /TID 

3) inj pantop 40 mg iv/ OD 

4 ) inj zofer 4 mg iv/sos

5) plan to get CECT abdomen today and also gastro opinion 

AMC BED 7

DAY 2SOAP NOTES 27YR OLD MALE

S: pain still persists in left hypochondrium region and back

O:

PT C/C/C.

PR: 86BPM

BP: 100/ 70MMHG

P/A: TENDERNESS present in the left hypochondrium and epigastrium

A: chronic pancreatitis with pseudo cyst

P:

1. IVF RL NS @100 ml /HS

2. Inj Tramadol 1 amp in 100 ml iv TID 

3. Inj pantop 40 mg IV/OD 

4.inj zofer 4 mg iv /dos 

5.syrup cremaffin plus 15 ml po/HD

AMC BED 7

DAY 3SOAP NOTES 27YR OLD MALE

S: pain abdomen decreased 

O:

PT C/C/C.

PR: 84BPM

BP: 100/ 70MMHG

P/A:soft and non tender at left hypochondrium and epigastrium

A: chronic pancreatitis with pseudo cyst

P:

1. IVF RL NS @100 ml /HS

2. Inj Tramadol 1 amp in 100 ml iv TID 

3. Inj pantop 40 mg IV/OD 

4.inj zofer 4 mg iv /dos 

5.syrup cremaffin plus 15 ml po/HD

Ward case

DAY 5SOAP NOTES 27YR OLD MALE

S: pain abdomen subsided

O:

PT C/C/C.

PR: 84BPM

BP: 100/ 70MMHG

P/A:soft and no tenderness  

A: chronic pancreatitis with pseudo cyst

P:

1. IVF RL NS @100 ml /HS

2. Inj Tramadol 1 amp in 100 ml iv sos

3. Inj pantop 40 mg IV/OD 

4.inj zofer 4 mg iv /dos 

5.syrup cremaffin plus 15 ml po/HD

6. Plan USG guided drainage of pseudo cyst or cysto- gastrostomy

Ward case

DAY 6 SOAP NOTES 27YR OLD MALE

S: no fresh complaints 

O:

PT C/C/C.

PR: 82BPM

BP: 100/ 60MMHG

P/A:soft and no tenderness  

A: chronic pancreatitis with pseudo cyst

P:

1.TAB tramadol 1/2 tab sos

2. TAB pant op 40 mg po/OD 

3.TAB zofer 4 mg po/sos

4.syrup cremaffin plus 15 ml po/HD

5.plan for discharge