I am Mridul Tak, a final year MBBS student, and this is an online elog documenting de-identified patient health data after taking his signed consent to enforce a greater patient centered learning.
DEIDENTIFICATION -
The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.
MRIDUL TAK
ROLL No. 88
30th March 2022
CASE DISCUSSION -
28 year old male, resident of Hyderabad and tailor by occupation came to OP with C/O pain abdomen since 3 days and 2 episodes of vomitings.
HOPI -
Patient was apparently asymptomatic 4 days ago then he went to a Feast where he ate Chicken Biryani, later then he developed pain in epigastric region which was sudden in onset colichy type, radiating to back, and 2 episodes of vomiting.
Pain aggrevated on taking meals and relieves on leaning forward.
3 days back he went to the RMP because of the pain, after taking medication pain decreased for 1 day, but on the next day pain increased.
Vomiting was non projectile, non bilious, with food particles as the content.
No history of loose stools, constipation, fever, trauma and weight loss.
Past History -
No history of similar complaints.
Not a known case of DM, hypertension,CAD,asthma,TB.
Treatment History -
He underwent endoscopic examination 8 years back.
Personal History -
Diet:mixed.
Sleep: disturbed sleep since 3 days.
Appetite: Decreased since past 2 days
Bowel and bladder: regular.
No addictions and allergies.
Family History -
No similar complaints in the family.
General Examination -
Patient was conscious,coherent and cooperative.
Built is moderate.
There is no pallor,icterus,cyanosis, lymphadenopathy, clubbing, edema.
Vitals-
Temperature: afebrile
Pulse rate:77/min
Respiratory rate:16/min.
BP:112/74
Spo2:97%
GRBS:109 mg %
Systemic Examination -
CVS:
S1 and S2 are heard.
No murmurs.
Respiratory examination:
There is no dysnoea,wheeze.
Breath sounds are vesicular.
Abdominal examination:
Inspection-
Shape of the abdomen:scaphoid
Umbilicus: Midline and inverted.
No scars and sinuses.
No engorged veins.
Palpation-
Tenderness is present in epigastric region.
No local rise of temperature.
Liver and spleen are not palpable.
Auscultation-
Normal Bowel sounds heard.
CNS-
Sensory and Motor responses are normal.
Investigations-
HEMOGRAM-
HB 16.3grm/dl
TC 17,100cells/cumm (normal-4000-10000)
PLT 3.38
MCV 82.5
PCV 46
MCH 29.2
MCHC 35.4
SMEAR - NORMOCYTIC NORMOCHROMIC
BGT- O positive
RBS- 124
RFT-
Urea 50mg/dl (normal-12-42)
Creatinine 0.9mg/dl (normal-0.9-1.3)
S. Sodium 140mEq/L(normal-136-145)
S. Potassium 3.8mEq/L(normal-3.5-5.1)
S. Chloride 98mEq/L(normal-98-107)
Pancreatic Enzymes-
S. Amylase 124 IU/L(normal-13-60)
S. Lipase 528IU/L(normal-25-140)
LFT-
TB 1.38mg/dl (normal 0-1)
DB 0.45 mg/dl(normal-0.0-0.2)
AST 36 IU/L(normal-0-31)
ALT 21IU/L (normal-0-34)
ALP 117IU/L(normal-42-98)
TP 6.7gm/dl(normal-6.4-8.3)
ALB 3.73gm/dl(normal-3.5-5.2)
SEROLOGY:
NEGATIVE
BLOOD SUGAR LEVELS:
RBS-124mg/dl
USG-
XRAY-
Acute pancreatitis secondary to gall stones.
Treatment-
Inj.Tramadol
Ringer lactate-IV.
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