50 yr Male came with stomach pain and vomiting

 I am Soumya 5th semester student .


This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them

CASE SCENARIO:


50yr old male patient resident of kanagal , farmer by occupation, came with chief complaints of pain andomen in morning and vomiting from 8am morning 1 episode.

HISTORY OF PRESENTING ILLNESS 

The patient was apparently asymptomatic 3yrs back then he developed pain abdomen upper quadrant and vomitings of nearly 10 episodes at the time of pain with water and food contents ,greenish color as patient described. For which he went to hospital in nalgondaand got diagnosed acute pancreatitis admitted for 3 days and symptoms subsided on medication ,got discharged 

After 7 months he came to kims narketpally for same and got treated and discharged at request and went to other hospital. 

Now patient came with epigastric abdominal discomfort and vomitings since 8.am in the morning .


HISTORY OF PAST ILLNESS:

K/c/o diabetes mellitus since 10ys 

On medication 

N/k/o HTN ,epilepsy ,thyroid ,CAD

TREATMENT HISTORY:

On medication for diabetes

PERSONAL HISTORY:

Married

Occupation: farmer

Diet: Mixed , Non vegetarian 

Appetite: Normal

Bowels: regular

Micturation: normal and complaints of burning sensation from 1 week

Known Allergies: No

addictions. Chronica alcoholic for 30yrs drinks mandhu daily half bottle, stopped consuming from 3 yrs

Chews gutka rajcaini, betal leaves

Smokes chutta (tobacco) chronic since 15 yrs.e

FAMILY HISTORY:

Mother has HTN

General Examination. 

No Pallor,icterus , cyanosis, clubbing , lymphadenopathy, pedal edema 

VITALSVitals:

Temperature - 98.6F

BP:-120/80mmhg ,

PR:- 82bpm,

RR- 16 cpm, 

Spo2:-98%

GRBS:120mg%

Systemic examination:

CARDIOVASCULAR SYSTEM

Thrills: No

Cardiac sounds: S1 , S2

Cardiac murmurs: No

RESPIRATORY SYSTEM

Dyspnoea:No

Wheeze: No

Position of trachea: Central 

Breath sounds: Vesicular 

Adventitious sounds : No

ABDOMEN

Shape - Scaphoid 

No tenderness, palpable mass, No Fluid 

No bruits

Liver not palpable 

Spleen not palpable. 

Bowel sounds present.

CNS Examination:

Conscious coherent cooperative. 

Speech normal.

No signs of meningitis 

Cranial nerves, motor system, sensory system Normal. 

PROVISIONAL DIAGNOSIS:

Pain Abdomen ?? Gastritis 


INVESTIGATION:



















DIAGNOSIS :

Pain Abdomen ?? Acute gastritis 


TREATMENT:


30/8

1.INJ.TRAMADOL IV/TID

2.INJ.PAN 40 mg IV

3.INJ.ZOFER 4 mg IV /TID SOS

4.IV FLUIDS NS RL @ 100 ml


31/8

1.INJ.TRAMADOL IV/TID

2.INJ.PAN 40 mg IV/OD

3.INJ.ZOFER 4 mg IV /TID SOS

4.IV FLUIDS NS 

 RL @ 100 ml


1/9


  • Pt - c/c/c
  • Temp afebrile on touch
  • PR - 82 bpm
  • BP - 120/80 mmHg
  • RS -  BAE+, NVBS
  • CVS - S1 & S2 are heard    
  • P/A soft,NT

1.INJ.TRAMADOL IV/TID

2.INJ.PAN 40 mg IV

3.INJ.ZOFER 4 mg IV /TID SOS

4.IV FLUIDS NS with 1 amp OPTINEURON 75ml/hr

RL @ 100 ml

5.Allow soft diet


2/9

Pt - c/c/c

Temp afebrile on touch

PR - 82 bpm

BP - 120/80 mmHg

RS - BAE+, NVBS

CVS - S1 & S2 are heard    

P/A soft,NT

1.INJ.TRAMADOL IV/TID

2.INJ.PAN 40 mg IV

3.INJ.ZOFER 4 mg IV /TID SOS

4.IV FLUIDS NS with 1 amp OPTINEURON 75ml/hr

RL @ 100 ml

5.Allow soft diet


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