32 year male electrician

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 patient problem through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence input.


                   This E blog also reflect 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 attempts to understand the topic of patient clinical data analysis to develop my competency in reading and comphrending clinical data including history , clinical finding , investigation and come up with diagnosis and treatment plan....

A 32yr old male electrician by occupation came with the complaints of pain in epigastric region  since 20days, SOB since 2days and acute pancreatitis diagnosed from other hospital.
Vomitings 5 days ago, Cold since 6 days, Cough since 5 days.

**HISTORY OF PRESENT ILLNESS:-**

Patient was apparently asymptomatic 20 days back then had pain in the epigastric region which was tender and relieved for by medication and injection given by the RMP, then he had the similar type of the pain at mid night and was admitted in a Suryapet hospital where he was diagnosed as Acute pancreatitis and liver enlargement. He underwent treatment for nearly 4 days and then was referred to our hospital since he was having pleural effusion confirmed by chest x-ray.

There is history of 2 episodes of vomiting which are non projectile, non blood stained and content is food particles.

Complaints of cold since 6 days and cough since 5 days which was non productive. It has become productive since 3 days

Patient complains of shortness of breath on rest.

HISTORY OF PAST ILLNESS-

Lower left rib hairline fracture.
Renal calculi 5yrs ago managed by medications.
UTI with fever 6months ago.
Not k/c/o DM, HTN, Asthma, TB, epilepsy, COPD, CVD.

PERSONAL HISTORY-

DIET: mixed
APPETITE: reduced 
SLEEP: adequate
BOWEL MOVEMENTS: constipated
BLADDER MOVEMENTS: Normal
ADDICTIONS:
He is alcoholic since 15 years daily , 180ml/ day. last alcoholic beverage- 5th Oct.
Chewing of tobacco since 15 years ,1 packet /day.
ALLERGY: fish

GENERAL EXAMINATION-

Patient is c/c/c. Oriented to time place and person.
Has mild pallor,
No icterus, clubbing, cyanosis, lymphadenopathy, edema.
Has moderate build and nourishment.
Patient is afebrile 
Vitals:
BP:140/70mmHg
PR:78bpm
RR:23cpm
GRBS:201
SpO2:89%

SYSTEMIC EXAMINATION-
P/A-
Inspection:
shape: obese and symmetrical.
Flanks:free.
Skin over abdomen: normal
Umbilicus:normal.
There is a swelling in epigastric region 
No visible engorged veins, pulsations, peristalsis, scars or sinuses.
Palpation:
girth - 113 cm
No local rise of temperature.
Tenderness in all quadrants.
Liver is non tender and non pulsatile, smooth surface, hard in consistency, Sharpe edge.
Spleen is non palpable.
Percussion:
No fluid thrills
No shifting dullness
Auscultation:
Bowel sounds normal 
No bruits.

CVS:
No thrills or murmurs
S1,S2 heard.

 RS:

inspection:
shape - scaphoid 
No wheeze 
No scars , sinuses present.
Palpation:
no palpable mass,
Trachea- central
Auscultation:
Vesicular breath sounds 
decreased breath sounds in right infra scapular and infra axillary area
No dyspnea, no rhonchi.





Investigations- 






Diagnosis:-
 Acute interstitial pancreatitis secondary to alcohol consumption with bilateral pleural effusion with grade 1 fatty liver.

Treatment -
1. Inf NS+ RL @75ml/hr
2. Inj. Pan 40mg IV/OD
3. Inj. Optineuron 1 amp in 100ml NS/IV/OD over 30min.
4. O2 inhalation
5. Tab. Ultracet PO/BD
6. Inj. Tramadol 1amp in 100ml NS / IV/sos
7. Allow liquid diet if tolerated start to solid diet.
8.vital monitoring
9. Strict input/output monitoring





 



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