Prefinal Practical Examination
Prefinal Practical Examination
PREFINAL PRACTICAL
This is an online E logbook to discuss
our patients' 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 the available global online community of experts
intending to solve those patients clinical problems with the collective current
best evidence-based inputs. This e-log book also reflects my patient-centred
online learning portfolio and your valuable inputs on the comment box are
welcome.
Name: G Sai Manogna
Roll no: 33
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.
Following is the view of my case :
CASE PRESENTATION:
A 35-year-old male, who is a driver by occupation
has presented to the casualty on 03 January 2022 with the chief
complaints of
- Pain in the epigastric
region since 10 days
HISTORY OF PRESENT ILLNESS:
The patient was apparently asymptomatic 10 days ago
then he developed pain in the epigastric region after consuming alcohol. It was
sudden in onset, increasing in intensity and of squeezing type. pain is
persistent throughout the day. It later radiated to whole the abdomen. He went
to a local doctor who treated him symptomatically. Then he came here 7 days ago
for better treatment.
No complaints of nausea and vomiting
PAST HISTORY:
- a similar episode in
June 2021 following continuous drinking for 5 days. He got admitted
in drdo hospital and got treated with fluids and analgesics. He was
advised to cut down on drinking
- not a known case of
diabetes, asthma, jaundice, hypertension, epilepsy, TB.
- no history of gall
stones
- no previous surgical
history
PERSONAL HISTORY:
- decreased appetite
- takes mixed diet
- bowel movements:
irregular
- micturition: oliguria
- no known allergies
- addictions: alcohol
consumption for 10 years. Consumes 180ml almost everyday.
No similar complaints in
the family.
GENERAL EXAMINATION:
Done after obtaining consent, in a well-lit room,
in the presence of an attendant, with adequate exposure. The patient is
conscious, coherent, cooperative, well-nourished, well -oriented to time,
place, person.
- No pallor icterus,
Cyanosis, Koilonychia, Generalised Lymphadenopathy, Pedal oedema and
clubbing
VITALS at the time of admission:
- Temperature - afebrile
- Pulse rate- 97 bpm
- BP- 100/70 mm Hg
- Respiratory rate-
22/min
- SpO2: 98% at room air
SYSTEMIC EXAMINATION:
1. CVS: S1
& S2 heard
2. Respiratory system: bilateral air
entry present, normal vesicular breath sounds
3. CNS: no focal deficit
4. Abdomen:
- On inspection abdomen is distended, the umbilicus is inverted. No visible peristalsis, pulsations, engorged veins and no hernia sites. Has a scar from a previous RTA. Negative cullen's sign and grey turner's sign.
-
- Palpation: inspectory findings
confirmed. There is tenderness, guarding and rigidity. pain in thee
epigastric region.
- Auscultaion: bowel sounds heard,
no bruit
INVESTIGATIONS:
HEMOGRAM
LFT
SERUM ELECTROLYTES
SERUM CREATININE
RFT
CT
CHEST X-RAY
ABDOMEN X-RAY
PSYCHIATRIC REFERRAL
He was sent for psychiatric referral to evaluate for alcohol dependence
PROVISIONAL DIAGNOSIS:
Acute pancreatitis due to alcohol dependence.
TREATMENT:
1 ivf ns
and rl and dns @ 50 ml /hr
2 inj . pantop 40 mg iv/od
3 inj. zofer 4 mg iv sos
4. inj tramadol 1 amp in 100 ml na iv bd
5.inj buscopan 22 cc iv/sos
6.tab pcm 650 mg po/tid
7.grbs 6 th hourly
8 temp and i/o charting
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