14 year old male with complaint of abdominal pain

Anurag K Vaddadi 

Roll no 189

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

This E-log also reflects my patient centered online learning portfolio.

I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan.





Patient came to OPD with chief complaints  of 

Pain abdomen since 10 days 

Constipation since 10 days


HOPI:


Patient was apparently asymptomatic 4 years back then he developed pain abdomen and was reffered to  private hospital

 Pain  relieved on taking  NSAIDS.

At the age of 9 years patient was admitted with similar complaints to niloufer hospital and was diagnosed with pancreatitis and adviced to take regular medications.

 At the age of 13 years patient had similar complaints and was admitted in Care hospital and was diagnosed with Acute on Chronic pancreatitis and was on regular medications (Tab.CREON 25000)

From past 10 days patient had severe pain abdomen , relieved on taking medications and on bending forward position.

Aggravates on eating food .

H/o similar complaints 3 months back


PAST HISTORY: 


N/k/c/o DM, HTN,ASTHMA,TB, EPILEPSY


PERSONAL HISTORY:


DIET : On an advised diet of soft boiled food, millet based drink(ragi Jawa), fruits.

APPETITE: Decreased

SLEEP:Normal when not in pain

BOWEL MOVEMENTS: Difficulty in passing stool

BLADDER MOVEMENTS:Normal

 ADDICTIONS:No


GENERAL PHYSICAL EXAMINATION:


 Patient is Concious , Coherent , Cooperative, well oriented to time place and person

 

Vitals on admission:

 

    TEMP: 98.5F

    BP: 100/70MMHG

    PR: 82bpm

    SPO2: 98%

    GRBS: 94mg/dl



GENERAL EXAMINATION:


No pallor, icterus,cynosis, clubbing, lymphadenopathy, odema








                                         






SYSTEMIC EXAMINATION:




CVS: S1; S2 +,No murmurs heard

RS: BAE +

CNS: No focal neurological defect


Per Abdomen :


INSPECTION: 




Shape of abdomen: scaphoid

Umbilicus  : everted

No visible swellings, scars, sinuses ,engorged veins, 

No visible peristalsis or pulsations

 Palpation:  

No local rise of temperature

Tenderness + in epigastric region

Liver not palpable

Spleenomegaly present

Percussion: resonant 

Palpation: bowel sounds +


INVESTIGATIONS:


HEMOGRAM:





  CUE:





USG ABDOMEN 







BLOOD SUGAR:




LFT:



RFT:




LIPID PROFILE:





CHEST X RAY






ECG






Previous investigations 













CT SCAN OF WHOLE ABDOMEN:









CECT ABDOMEN:







DIAGNOSIS:


ACUTE ON CHRONIC PANCREATITIS 



TREATMENT:


1) NBM TILL FURTHER ORDERS

2) INJ PANTOP 40 MG /IV/OD

3)INJ ZOFER 4 MG IV/SOS

4)INJ.TRAMADOL 1AMP IN 100ML NS/IV/BD

5) IVF - NS&RL&DNS@ 100 ML /HR  

6) INJ NEOMOL SOS IF TEMP >101.1 F

7) MONITOR VITALS

Comments

Post a Comment

Popular posts from this blog

My experiences with general cellular and neural cellular pathology in a case based blended learning ecosystems

Image
  आरोग्यम् परमं भाग्यं स्वास्थ्य ्यं सर्वार्थ साधनम्। शरीरं सुखमायान्ति सततं  Translation : “ Good health is the greatest blessing, and well-being is the means to achieve all goals. In a body where health is constant, happiness always prevails. “ ज्ञानं परं बलं तपः। ज्ञानेन विनयो यत्र। ज्ञानाद्धर्मो यशः सुखं। ज्ञानेन विना न जीवनं॥ Translation : " Knowledge is the supreme power, the source of self-discipline.  Where there is knowledge, there is humility.  Through knowledge, one attains righteousness, fame, and happiness.  Without knowledge, life is meaningless." In my belief, Since the inception of philosophy and medical science, knowledge and health combined together uphold the prosperity of the human race. Moreover, it helps humans in sustaining the thing that’s most precious to them, life. Greetings. I am Anurag Vaddadi, a medical student currently in final year of MBBS and welcome to my memoir of clinical experiences regarding Clinical based blended learning and blogging
Read more

57 yr old female with fever and Burning Micturition

Image
 This is an E log book to discuss our patients de-identified health data shared after guardians informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve this patients clinical problems with collective current best evidence based inputs. This E-book also reflects my patients centered online learning portfolio and your valuable comments in comment box are most 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 and comprehending clinical data including history,clinical finding investigations and come up with a diagnosis and treatment plan.
Read more

A case of 32 yr male with Rt sided pleural effusion

Image
This is an E log book to discuss our patients de-identified health data shared after guardians informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve this patients clinical problems with collective current best evidence based inputs. This E-book also reflects my patients centered online learning portfolio and your valuable comments in comment box are most 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 and comprehending clinical data including history,clinical finding investigations and come up with a diagnosis and treatment plan.
Read more