acute pancreatitis

Pt aged 45 years old male came to opd with chief complaints of vomitings ,abdominal pain and low grade fever since 1 day

HOPI-:Patient was apparently asymptomatic 1day back then he developed sudden vomitings, abdominal pain and low grade fever
PAIN-:
Type-:dragging type of pain 
Site -:epigastric region 
VOMITING-:4-6 BOUTS IN A DAY
        TYPE-:BILIOUS TYPE OF VOMITING
No h/o-:constipation 
No h/o-:loose stools
ALCHOHOL HISTORY-:Since 5years with a gap of 1 year in between and again continuing since 3-4months 
Quantity-:1beer/day

HISTORY OF PAST ILLNESS-:
                    similar complaints in the past 5 years ago
N/K/C/O-: diabetes ,TB,asthma ,epilepsy,Hypertension 

PERSONAL HISTORY-:
         Diet-:mixed
         Appettite-:normal 
         Bowel and bladder -:regular
        Sleep-:normal
         Addictions-: alcohol--->regular
                                1beer/day

FAMILY HISTORY-:no similar complaints in family members 

GENERAL EXAMINATION-:
NO SIGNS OF -: PALLOR
                            ICTERUS
                            CLUBBING
                            CYANOSIS
                            LYMPHADENOPATHY 

VITALS-: 
             Temp-:98.7f
             Pulse rate-:66
            Bp-:120/80
            Spo2-:97
            Resp rate-:12cycles/min 
  
SYSTEMIC EXAMINATION 
       CVS-: No thrills heard
                  Heart sounds normal
                   No murmurs heard

      RESPIRATORY -:
                   No dyspnea,wheeze
                    Position of trachea -central 
       ABDOMEN-:
                     SHAPE-:scaphoid
                     Tenderness-:+ve in epigastric region
                  No palpable masses 
                  No free fluid 
                  Liver-:not palpable
                  Spleen-: not palpable
                 Bowel sounds -:heard


INVESTIGATIONS-:
           SERUM AMYLASE-:
   
          SERUM LIPASE-:
      
            SERUM CREATININE-:
   
       
          SERUM UREA-:
TREATMENT-:
INJECTION TRAMADOL 
INJECTION THIAMINE

Comments

Post a Comment

Popular posts from this blog

CKD CASE

CKD CASE 20,06,2022 CASE SCENARIO  Pt aged 70 years came to opd with chief complaints of flank pain and decreased urine output  HISTORY OF PRESENT ILLNESS  Since a week pt has flank pain and decreased urine output   HISTORY OF PAST ILLNESS Pt was asymptomatic 4years back than he met with an accident for which he has been taking medication for pain as post operative medication for pain as a result of chronic use of pain medication pt's kidneys got gradually damaged which resulted in kidney failure  TREATMENT HISTORY  patient is on hypertensive therapy since 3 years and pain killers  PERSONAL HISTORY  Regular bowel habbit  Mixed diet  Decreased urine out put  PHYSICAL EXAMINATION  .patient is conscious,coherent ,and cooperative  .moderately built and moderately nourished  .No signs of --pallor                           .icterus                           .clubbing                           .cynosis     .no edema present    .  VITALS   .Temperature-:98.4F   .pulse rate     -:86   .Rp 
Read more

DIABETIC KETOACIDOSIS

Image
A50 yr old female came to GM OPD with chief complaints of fever, vomiting, difficulty in breathing. HISTORY OF PRESENTING ILLNESS:- patient was apparently asymptomatic 2 weeks back then she developed fever of low grade with vomiting 4 episodes per day which is non-bilious, non-projectile. HISTORY OF PAST ILLNESS:- K/C/O- DM since 20yrs K/C/O- HTN since 20yrs. Not a K/C/O of TB, ASTHMA, EPILEPSY TREATMENT HISTORY:- METFORMIN since 20yrs TELMISARTAN since 20yrs PERSONAL HISTORY:- Diet- mixed Appetite- normal Bowel and bladder habits- regular Burning micturition No addiction FAMILY HISTORY:- Not significant PHYSICAL EXAMINATION:- #GENERAL:- No pallor No icterus No cyanosis No clubbing No lymphadenopathy Vitals:- B.p- 140/90mmHg Pulse-  Temp- Afebrile Respiratory rate- 18/min #Systemic examination:- CVS- S1,S2 heard           No cardiac murmurs           No thrills Respiratory system- dyspnoea present                                       No wheeze                                       Pos
Read more

HEART FAILURE WITH MID RANGE EJECTION FRACTION( EF 44%) WITH RIGHT LOWER LOBE COLLAPSE WITH BRONCHIECTASIS WITH RIGHT MIDDLE LOBE PLEURAL EFUSION WITH CHRONIC PANCREATITIS WITH SEPSIS WITH GRADE 2 BED SORE WITH K/C/O DM II SINCE 20 YEARS WITH K/C/O CAD-S/P: PTCA DONE 2 YEARS AGO D9-S/P: TRACHEOSTOMY

Case History and Clinical Findings  PATIENT CAME WITH C/O LOWER BACK ACHE SINCE 3 WEEKS RADIATING TO LEFT LOWER LIMB  HOPI:PATIENT WAS APPARENTLY ASYMPTOMATIOC 3 WEEKS BACK SINCE THEN, PATIENT COMPLAINTS OF LOWER BACK ACHE WHICH IS SUDDEN ONSET,NON PROGRESSIVE,AGRAVATES ON MOVEMENT RELEIVES ON REST H/O TRAUMA(SLIP AND FALL FROM STEPS) 3 WEEKS BACK ,WAS TAKEN TO OUTSIDE HOSPITAL FOUND TO HAVE L5 BURST FRACTURE ON CT PELVIS AND CAME HERE FOR FURTHER MANAGEMENT NO H/O LIFTING OF HEAVY WEIGHTS,FEVER BURNING MICTURITION BOWEL AND BLADDER INCONTINENCE PAST HISTORY OF RIGHT PROXIMAL FEMUR FRACTURE AND DONE IMILN 10 YEARS BACK. H/O PTCA DONE ONE AND HALF YEAR BACK AND IS ON REGULAR MEDICATION  K/C/O DM II SINCE 20 YEARS AND IS ON T. METFORMIN 500 MG + T. VOGLIBOSE 0.2 MG + T. GLIMIPERIDE 2 MG GENERALEXAMINATION:  PATIENT IS CONSCIOUS,COHERENT AND CO OPERATIVE NO SIGNS OF PALLOR,ICTERUS,CLUBBING,CYANOSIS,EDEMA AND LYMPHADENOPATHY  VITALS: TEMP:AFEBRILE BP: 110/80MMHG PR:80BPM RR:18CPM  SYSTEMIC
Read more