65YRS OLD MALE WITH PAIN ABDOMEN

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.

Here is a case i have seen:

A 65 yr old male came with complaints of

Pain abdomen since 7 days

Patient was apparently asymptomatic 7 days back then he developed pain abdomen in the umbilical region which was insidious in onset and gradually progressive after a binge of alcohol 3 days back, stabbing type of pain,   relieves on taking medication, no aggravating factors, no radiation. 

No h/o vomiting, loose stools

No h/o chest pain, palpitations, sob

PAST HISTORY : 

Similar complaints in the past (2yrs back) 

He had pain abdomen for 4 days which was stabbing type in umbilical region, no aggravating factors, no radiation,  he got admitted im kims nkp got treatment (hospital stay 7 days). Adviced not to drink alcohol n smoke. 

No history of DM, Htn, asthma, epilepsy, TB, CAD

PERSONAL HISTORY :

smoking since 15yrs -  18 Beedis per day 

Alcohol  since 15yrs - 90ml whisky. He stopped alcohol for 1yr after the previous episode then started drinking again , 90ml whisky daily. 

ON EXAMINATION:

Patient is conscious, coherent, not cooperative

GENERAL EXAMINATION :

Pallor- absent 

Icterus - absent 

Clubbing - absent 

Cyanosis- absent 

Lympadenopathy - absent

Edema- absent 

VITALS: 

SPO2: 98% ON RA

TEMPERATURE : AFEBRILE

BP: 130/90 MMHG 

PR: 64BPM 

RR: 20 CYCLES /MIN

GRBS: 120 mg%


SYSTEMIC EXAMINATION :

Per abdomen: 

 soft, tenderness in umbilical region

Bowel sounds present

    No organomegaly. 

CVS : 

       S1, S2 heard

        No murmurs

RS: 

     B/L AE present

      No added sounds 

CNS: 

No focal defici 


INVESTIGATIONS:

          CT ON 30/10/2020



1. RFT:

Urea: 49,  Creatinine: 1.0,  Uric acid: 5.5

Calcium: 10.2,  Phosphate : 3.3

Sodium : 141, Potassium : 3.2, Chloride: 101

2.CUE: 

Pus cells: 2-4,  Epithelial cells: 2-3

3.CBP

4. RBS

5. LFT

6. SERUM AMYLASE 

7.CXR


8. ECG
9.USG 

DIAGNOSIS:

? ACUTE  ON CHRONIC PANCREATITIS


TREATMENT :

DAY 1:  31/10/2020

1. IV FLUIDS - DNS, RL @ 100ML/HR               CONTINUOUS

2. INJ. THIAMINE 1AMP IN 100ML NS IV/TID

3. TAB. PAN 40MG IV OD

4. INJ. ZOFER 4MG IV SOS

5. INJ.TRAMADOL 1AMP IN 100ML NS  IV/SOS

6. I/O CHARTING

7.MAINTAIN TEMPERATURE, PR, BP, GRBS 4TH  HOURLY. 

8.GRBS 6TH HOURLY


DAY 2 : 1/11/2020

No fresh complaints

Pt is conscious, coherent, cooperative

Vitals:

SPO2: 98% ON RA

TEMPERATURE : AFEBRILE

BP: 130/80 MMHG 

PR: 64BPM 

RR: 20 CYCLES /MIN

GRBS: 138 mg%

P/A : soft, non tender, bowel sounds +

CVS: S1, S2 +

RS: BAE+

Rx : 

1. IV FLUIDS - DNS, RL @ 100ML/HR CONTINUOUS

2. INJ. THIAMINE 1AMP IN 100ML NS IV/TID 

3. TAB. PAN 40MG IV OD

4. INJ. ZOFER 4MG IV SOS

5. INJ.TRAMADOL 1AMP IN 100ML NS IV/SOS

6. I/O CHARTING

7.MAINTAIN TEMPERATURE, PR, BP, GRBS 4TH HOURLY. 

8. GRBS 6TH HOURLY 


DAY 3 : 2/11/2020

Complaints of pain abdomen decreased since yesterday evening

Pt is conscious, coherent, cooperative

Vitals:

SPO2: 98% ON RA

TEMPERATURE : AFEBRILE

BP: 130/80 MMHG 

PR: 64BPM 

RR: 20 CYCLES /MIN

GRBS: 138 mg%

P/A : soft, non tender, bowel sounds +

CVS: S1, S2 +

RS: BAE+


Rx : 

1. IV FLUIDS - DNS, RL @ 100ML/HR CONTINUOUS

2. INJ. THIAMINE 1AMP IN 100ML NS IV/BD 

3. TAB. PAN 40MG IV OD

4. INJ. ZOFER 4MG IV SOS

5. INJ.TRAMADOL 1AMP IN 100ML NS IV/SOS

6. I/O CHARTING

7.MAINTAIN TEMPERATURE, PR, BP, GR BS 8TH HOURLY. 

8. GRBS 8TH HOURLY


DAY 4:  3/11/2020

Pt is conscious, coherent, cooperative

Vitals:

SPO2: 98% ON RA

TEMPERATURE : AFEBRILE

BP: 120/70 MMHG 

PR: 72BPM 

RR: 20 CYCLES /MIN

GRBS: 90 mg%

P/A : soft, non tender, bowel sounds +

CVS: S1, S2 +

RS: BAE+

Serum amylase: 108.2 IU/L

Rx : 

1. SOFT ORAL DIET,  PLENTY OF ORAL FLUIDS

2.IV FLUIDS - DNS, RL @ 100ML/HR CONTINUOUS

3. INJ. THIAMINE 1AMP IN 100ML NS IV/BD 

4. TAB. PAN 40MG IV OD

5. INJ. ZOFER 4MG IV SOS

6. INJ.TRAMADOL 1AMP IN 100ML NS IV/SOS

7. I/O CHARTING

8.MAINTAIN TEMPERATURE, PR, BP, GR BS  8TH HOURLY. 

9. GRBS 8TH HOURLY

  



Popular posts from this blog

BIMONTHLY ASSESSMENT NOV-2020

1) " 55 year old male patient  came with the complaints of  Chest pain since 3 days Abdominal distension since 3 days Abdominal pain since 3 days and decreased urine output since 3days and not passed stools since 3days  https://sreejaboga.blogspot. com/2020/11/is-online-e-log- book-to-discuss-our.html?m=1 Intern's presentation:  https://youtu.be/Pn5tidICB8A PGs discussion:  https://youtu.be/9caUzjXYuqo a) Where are the different anatomical locations of the patient's problems and what are the different etiologic possibilities for them? Please chart out the sequence of events timeline between the manifestations of each of these problems and current outcomes.  A.  ANATOMICAL LOCATIONS WITH ETIOLOGY: GIT (Pain abdomen) : Etiology: Pancreatitis secondary to ? chronic alcoholism KIDNEYS (Oliguria) : Etiology: AKI (pre renal due to fluid loss in.             pancreatitis)      Sepsis induced ATN HEART / LUNGS (SOB) : Etiology: AKI leading to fluid overload and heart failure. Pan
Read more

PT AND APTT

Image
1. COLLECT BLOOD IN BLUE VACUTAINER 2. PUT THE BLOOD IN TUBE AND KEEP IN THIS TO SEPARATE SERUM FROM PLASMA 3. TAKE ANOTHER TUBE WITH UNIPLASTIN FOR PT   LIQUICELIN-E FOR APTT 4. KEEP THE TWO TUBES IN HOT AIR OVEN  TAKE THE TUBES OUT  5. NOW TAKE THE BLOOD WITH THIS PIPETTE 6. NOW ADD THE BLOOD INTO THE TUBE CONTAINING REAGENT EVERY SECOND AND COUNT THE TIME WHEN BLOOD CLOTS.  7. NORMAL PT : 10-16 sec          NORMAL APTT : 24-33 sec
Read more

BIMONTHLY EXAM

                          CASE 1       This is a case admitted in my unit , so patient is a 57 yr old male with poor lifestyle habits and obesity and chronic alocholic .  https://swathibogari158.blogspot.com/2020/09/chronic-decompensated-liver-disease.html 1. What is the reason for this patient's ascites?   A.  Ascites is defined as the presence of excessive fluid in the peritoneal cavity.          Reasons for Ascites:       . CHRONIC LIVER DISEASE (ALCOHOL             INDUCED LIVER CIRRHOSIS)       .  HYPOALBUMINEMIA      .  TRUNCAL OBESITY >> METABOLIC                    SYNDROME >> NAFLD >> CIRRHOSIS         MECHANISM:        Portal hypertension ----splanchanic             vasodilation---decreased renal blood flow ----     RAAS system activation------Sodium water.         retention.   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860926/#:~:text=Ascites%20is%20defined%20as%20the,resulting%20in%20renal%20sodium%20retention   2. Why did the patient develop bipeda
Read more