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