40yr old with Pain Abdomen

47 M came with chief complaints 
 -Fever since 2 days 
-vomiting since 2 days
-pain in  abdomen since  2 days 
-Burning micturition since 2 days
HOPI:
patient was apparently asymptomatic 2 days ago, then he developed fever which is ,intermitent, associated with chills and rigor,relieved on medication,
- vomiting from 2 days, food as content,non -projectile,3 episodes / day
-pain in  abdomen from 2 days, pricking type,non radiating,in right hypochondrium
- burning micturition from 2 days
-uprolling of eyes,stiffness of both upper limbs yesterday 
PAST HISTORY:
K/C/O epilepsy 15 years ago, 3 episodes 
N/k/C/O Diabetes mellitus,asthma,tb
H/O fracture of left lower limb 15 years ago and operated 
PRESENT HISTORY:
Appetite -Nornal
Diet-Mixed
Sleep-Adequate
Bladder habits-regular
Bowel habits-regular
Addiction:used to binge alcohol 15 years ago ,then after drinks occasionally
GENERAL EXAMINATION:
patient is conscious, coherent, co-operative,well oriented to time,place, person
No pallor,icterus,cyanosis, clubbing,pedal oedema,lymphadenopathy




Vitals:
PR:82bpm
BP:140/70mm Hg
Temperature:97F
RR:24cpm

SYSTEMIC EXAMINATION:
ABDOMINAL EXAMINATION:
Inspection:
Shape of abdomen:Scaphoid
Umbilicus:Central
All quadrants moving equally with respiration
No scars, sinuses,engorged veins
Palpation:
All inspectory findings are confirmed
No local rise of temperature,no tenderness
No gaurding , rigidity
No organomegaly
Percussion:
Reasonant note upto 5th ICS
No fluid thrill
Auscultation:
Bowel sounds heard

INVESTIGATIONS:
CBP:
15/10/22
16/10/22


LFT:


RFT:
15/10/22
16/10/22










15/10/22
16/10/22
17/10/22



Treatment:
Day1
1)NBM till further orders
2)IVF -NS,RL,DNS@50 ml/hr
3)INJ.MONOCEF 1 gm /IV/BD
4)INJ.METROGYL 500mg /IV/TID
5)INJ.PAN 40 mg IV/OD
6)INJ.ZOFER 4 mg IV/OD
7)INJ.TRAMADOL 1 AMP IN 100 ml NS/IV/BD
8)T.LEVIPIL 500mg PO/BD
PROVISIONAL  DIAGNOSIS:
INFLAMMATORY BOWEL DISEASE



Comments

Post a Comment

Popular posts from this blog

80 year old Male with chief complaints of burning micturition, pain abdomen and SOB

Image
80yr old male came to the OPD with chief complaints of: Fever since 10days Burning micturition since 1day Decrease urine output since 1day Pain in left loin region since 1day Shortness of breath HOPI: Patient was apparently asymptomatic 10days back then he developed fever which is high grade , intermittent which is not associated with cold/cough/chills and rigors which subsided on taking medication. Later he developed burning micturition, pain abdomen ( left loin region) which is non radiating and dragging and decreased urine output with dark yellow coloured urine since 1day. He had a sudden episode of diminished mentation associated with spontaneous micturition yesterday PAST HISTORY:- K/c/o hypertension since 1 year N/k/c/o DM, TB, Asthma, Thyroid disorder, Epilepsy. H/o kidney infection 4 years back which relieved on treatment (similar  loin pain- may be pyelonephritis - complained hematuria and burning micturition) H/o trauma to Right Lower end of tibia- fracture, malunion FAMILY H
Read more

38 yr old with Pain Abdomen

Image
A 38yr old male resident of West Bengal , civil engineer by occupation came to the OPD with chief complaints of abdominal pain since 5 years HOPI :- Patient was apparently asymptomatic 5 years back then developed pain abdomen which is sudden in onset , gradual in progression , dragging type radiating to back which aggravates on intake of food, alcohol and relieved on medication.  From last 5 years he has episodes of abdominal pain occurring once in 3 months later from last 6 months pain occurs more frequently/daily? For the past 1 year patient has episodes of vomiting followed by pain in abdomen at least once in 2 months which is non bilious and water as content associated with weakness and giddiness On13th November he had multiple episodes of vomiting after lunch, initially vomiting containing food particles (yellowish)  later watery associated with weakness and giddiness and not relieved on medication. On 23rd November he had similar episode of pain and took medication He also compla
Read more

1801006118 - LONG CASE

Image
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-centred online learning portfolio and your valuable comments on comment box is welcome. I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.   A 50 year old male, resident of Miryalagudem ,  ice factory worker by occupation presented with the chief complaints of  Weakness in the right upper and lower limbs since 7 days  slurr
Read more