32M PAIN ABDOMEN AND VOMITING SINCE 1 DAY, FEVER SINCE 4 DAYS.
32M PAIN ABDOMEN AND VOMITING SINCE 1 DAY, FEVER SINCE 4 DAYS.
This is an E-Log, that depicts the patient centered approach for learning medicine .This E-Log has been created after taking consent from the patient and their relatives. The links that were used by me for understanding the available data on the particular disease have been mentioned below in each post . Hope you learn valuable information after giving it a good read!
CHIEF COMPLAINTS:
C/o vomiting since 1 day.( 10-15 episodes)
- non bilious
- non projectile
- immediately after drinking water or eating food
C/o pain abdomen since 1 day
- epigastric region
- non radiating
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 4 days back then developed fever, low grade, intermittent type. Patient had 1 episode of involuntary movement (seizure) with loss of consciousness.
PAST HISTORY:
Not a k/c/o hypertension, diabetes type 1 and 2, coronary artery disease, Epilepsy, CAD.
IN june 2020 Patient admitted in our hospital and was diagnosed- acute pancreatitis resolved with resolved AKI with resolved pleural effusion with acute liver failure ( resolved ).
FAMILY HISTORY:
No significant family history.
PERSONAL HISTORY:
Appetite: normal
Diet:mixed
Bowel:regular
Micturition: normal
Addiction : alcohol (90 ml daily) since 10 years.
General examination;
Pallor absent,
No icterus,cyanosis, clubbing,pedal edema. no lymphadenopathy
VITALS:
Temp- 98.4 F
PR - 86 bpm
BP- 80/50 mmHg
RR- 36CPM
Systemic examination
CVS- S1,S2 heard,no murmurs
RS - BLAE, NVBS +
Per abdomen: abdomen distended, non tender
CNS - patient is conscious coherent and cooperative.
No neck stiffness
NORMAL
MOTOR SYSTEM-
TONE UL LL
RT N N
LT N N
SENSORY SYTEM - NORMAL
GLASGOW SCALE- 15/15
REFLEXES
BICEPS TRICEPS SUPINATOR
RT 2+ 2+ 2+
LT 2+ 2+ 2+
KNEE ANKLE
RT 2+ 1+
LT 2+ 1+
Ecg taken on 25/11/23 11:20 am
LAB INVESTIGATIONS:
X RAY PA VIEW:
PROVISIONAL DIAGNOSIS:
Alcoholic liver disease with Acute Pancreatitis with hypoglycemia
TREATMENT:
1. Nil per oral except clear fluids.
2. Iv fluids DNS/RL @125 ml/hr.
3. Inj pan 40 mg IV/BD
4. Inj thiamine 500 mg in 100 ml NS Iv/od
5. Inj ceftriazone 1 gm iv/bd
6. Inj emeset 8 mg iv ( 8th hourly)
7. Inj vit k 10 mg iv/od
8. Tab Rifagut 550 mg po/bd
9. Syp lactulose 10 ml po/bd, in one glass of water.
10. Inj Tramadol 50 mg in 100 ml NS iv 8th hourly.
11. Tab nodosis 1 gm po/bd
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