GENERAL MEDICINE E-LOG


SUPRIYA GAGIREDDY 42

Hi,I am supriya 8th sem medical student.This is an online elog book to discuss our patients de-identified health data shared after taking his/her/guardians signed informed consent.Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.This E-log book reflects my patient centered online portofolio          

40 yr old male patient who is daily wage labourer by occupation came to OPD with

 chieft complaints :

of pain abdomen since 5 days associated with fever since 2 days .


History of present illness 


Patient was apparently asymptomatic 5 days ago then he developed pain which is insidious in onset and gradually progressive which is diffuse , squeezing type and radiating to back .
Pain is relieved on medication .
No C/O of vomitings , loose stools , burning micturition ,cough,cold , chest pain , SOB 

.
History of past illness

N/K/C/O TB , hypertension, diabetes, Asthma, epilepsy , CAD, thyroid disorders .

Personal history 
Diet - mixed 
Appetite- normal
Bowel and bladder -regular
Sleep - adequate
Addictions - regular alcohol intake of 250 ml per day since 20 yrs .
No food allergies and drug allergies


General examination

Pallor - yes 
Edema -absent 
Clubbing - absent 
Lymphadenopathy - absent 
Icterus - absent 

 
Vitals - 

Temperature - 100.1F
BP-85/60
Spo2- 98%
RR-20pm
PR- 100/min
 Systemic examination

Per abdominal examination:

Patient exposed from nipple to mid thigh and examined in supine position 

INSPECTION: 


Shape:Distended flanks full 

Umbilicus:inverted,vertically drawn down

Skin over the abdomen is shiny

No visible peristalsis,



Palpation:

On superficial Palpation 


All inspectory findings are confirmed 

Tenderness+

,diffuse all quadrants

No Rebound tenderness 

No guarding,rigidity

Percussion



Shifting dullness absent 

fluid thrill absent 

Liver span-12cm

Percussion of spleen : dullness in 9th inter coastal space of anterior axillary line 

Auscultation 

Bowel sounds+


No arterial bruit,



RESPIRATORY SYSTEM 

Inspection 

Shape of chest:Bilaterally symmetrical,Elliptical in shape

No visible chest deformities

Abdomino thoracic respiration,No irregular respiration

No tracheal shift

No dropping of shoulders, on both sides,no sinuses,scars,engorged veins



Palpation:inspectory findings confirmed by Palpation 


Chest movements -normal



Percussion:

Resonant note heard over all areas 

Auscultation: 

Norma vesicular breath sounds

, breath sounds normal 



Cardiovascular system:

Inspection:precordium normal,apex beat :5th ICS half inch medial to mid clavicular line

Palpation:inspectory findings confirmed,No thrills or parasternal heave



Auscultation: S1S2+,no murmurs



CNS:
patient is arousable 

No signs of meningitis 

cranial nerves intact,motor and sensory examination normal


No cerebellar or meningeal signs

Reflexes:

Knee 3+. 3+

Reflexes Rt. Lt 
Biceps 3+. 3+
Triceps 3+. 3+
Supinator 2+. 2+
Knee 3+. 3+

              Right. Left 
UL. 2/5. 3/5
LL. 2/5. 3/5



provisional diagnosis 

 Acute pancreatitis ( non necrotizing type) peripancreatic fluid collection.
Investigations:



















Treatment
1 .IV fluids 125ml/hr 
2.injec.zoffer 4 mg IV
3.inj Tramadol 1 ampoul in 100ml NS
4.inj piptaz 4 to 5 mg 
5. Inj pan 40 mg IV
6.inj neomol 1gm IV

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