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 an comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
B.Gayathri. Roll no (22)
CASE
Chief complaints:
Diffuse abdominal pain since 4 days.
History of presenting illness:-
Sequence of events:-
Patient was apparently asymptomatic 4 years ago then he had joint pains (wrist joint, ankle and knee) for which he consulted doctor and was diagnosed as polyarthritis.
Then on 16thmarch he had pain in the epigastric region at midnight .Then the pain gradually increased to severity till morning .squeezing type radiating to back associated with vomitings 3 episodes per day with food particles as content,non bilious and non projectile.pain aggrevated on sitting and decreased on sleeping in right lateral position.Then it was diagnosed as acute pancreatitis.Then he was diagnosed with hypertension and diabetes for which he is on medication.
On saturday (02-07-22) he had alcohol and lunch after that he developed diffuse abdominal pain which was aching type aggrevated on eating food no relieving factors and it is not associated with vomitings,diarrhoea.For that he went to local hospital and stayed for 3 days on wednesday and on wed he had an episode of fever associated with chills and also hematuria for which they have consulted our hospital on 02-07-22 evening.
Fever was intermittent type with no aggrevating and relieving factors.no complaints of pedal edema ,shortness of breath.
Daily Routine:-
He studied till tenth and he worked as an idly vendor for about 10 years then he used to drink daily but not a heavy drinker (90 ml per day .)
After that before 7 yrs he bought auto and present he is an auto driver .Now he used to drink daily morning and night compulsory for about 400ml .He used to do breakfast in the morning after taking alcohol and dinner in night.He has no habit of eating lunch he used to drink tea only during lunch time.
He is a chronic alcoholic since 17 yrs.
Past history:
Known case of diabetes,hypertension since 6 months k/c of acute pancreatitis
Not a known case of asthma,tuberculosis.
Personal history:
Diet-mixed
Appetite- normal
Sleep - adequate
Bowel and bladder movements- regular
Habits- alcoholic since 17yrs (400 ml per day),
Chews gutka everyday since 17 yrs.
FAMILY HISTORY:
No similar complaints in the family members
GENERAL EXAMINATION:
Patient is conscious coherent and cooperative.
Well oriented to time place and person.moderatly built and nourished.
Pallor -
Icterus: absent
clubbing: absent
cyanosis: absent
Lymphadenopathy: absent
Edema : absent
VITALS:
Temp: afebrile
BP: 100/80 mmHg supine position
PR- 90 bpm
RR- 16cpm
SYSTEM EXAMINATION:
Abdominal examination-
flat,all quadrants are moving according to respiration .umbilicus is central and inverted,no engorged veins,no scars,no sinuses
Tenderness present in right hypochondrium and epigastric region .
No guarding
,no rigidity,liver dullness in 5th intercoastal space, bowel sounds present.
Respiratory system-inspection- trachea central,normal respiratory movements,normal vesicular breath sounds.
Cardio vascular system- S1 ,S2 heard ,no murmurs
CNS Examination- no focal neurological deficits..
Investigations:
Provisional diagnosis:
Alcoholic gastritis .
Treatment:
Thiamine 200mg in 100ml normal saline IV
Injection Pantop 80mg in 500ml nomal saline
Injection Telma 20mg once daily
Injection HAI subcutaneously three times per day acc to GRBS
Follow up:-
He had an episode of fever with chills yesterday night (07-07-22).His abdominal pain is increasing when he takes food.
He has not been able to eat since 02/07/2022 and ryle's tube has been advised today.
- No hematuria since yesterday.
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