FINAL EXAMINATION SHORT CASE

-

 A 22 YEAR OLD MALE WITH PANCREATIC PSEUDOCYST


This is an online E log book to discuss our patient's de-identified health data shared after taking her guardian's signed informed consent.

Name : SOWJANYA REDDY PALAKURTHY

Hall Ticket Number : 1701006175

Roll no. - 130 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.This E-log also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are welcome.

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.


CONSENT : An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references. 


 DOA: 7/6/2022


A 22yr old male patient, painter by occupation , resident of nalgonda came with 


CHIEF COMPLAINTS:


Pain abdomen since 4 days.


HISTORY OF PRESENTING ILLNESS:


5 YEARS AGO

Pt. Has started consuming alcohol 4 yrs back due to peer pressure , intially taking one peg per day which has increased to 90ml morning and evening i. e twice daily.  He has stopped consuming alcohol 3 months back as advised by the doctor.


2 YEARS AGO

Pt. Has history of smoking since 2 yrs . He has been smoking 5 beedis/per day till date.


3 MONTHS AGO

Pt was apparently asymptomatic 3 months back then he developed abdominal pain which was dragging in character for which he was admitted in near by hospital in nalgonda . He was diagnosed with acute pancreatitis and was treated inadequately  and was advised to stop consumption of alcohol. 


Since then pt has stopped consuming alcohol and has been experiencing alcohol withdrawal symptoms like  getting angry , agitation , irritability , craving to consume alcohol, tremors .


4 DAYS AGO

 Pt had consumed alcohol  4 days back due to fight with his wife.


On 7/6/2022

In veiw of this symptoms pt.has been brought to psychiatry OPD for deaddiction. He was referred to medicine OPD in veiw of pain abdomen.


Pain was , insidious in onset , started after consuming of alcohol in epigastrium and left hypochondrium which was relieved on bending forward and lying down , aggregated on eating food and standing straight.


No h/o fever , nausea , vomiting, sweating.


No h/o Chest pain , shortness of breath , constipation


Flatus passed





PAST HISTORY:


H/o similar complaint in past 3 months back.


Not a known case of DM, HTN, BA, Epilepsy, TB.


No h/o previous surgeries 


FAMILY HISTORY :


Insignificant 


PERSONAL HISTORY 


  • DIET : mixed 
  • APPETITE : decreased 
  • BOWEL AND BLADDER: regular 
  • SLEEP: inadequate 


GENERAL EXAMINATION :


Patient was examined in a well lit room. Henwas conscious, coherent and cooperative; Thin built and moderately nourished


Pallor - present




No icterus, cyanosis , clubbing, lymphadenopathy, edema


VITALS- at the Time of admission


  • Temperature- afebrile
  • Pulse rate- 94bpm
  • Blood pressure-120/80mmHg
  • Respiratory rate- 16cpm


SYSTEMIC EXAMINATION 




1. ABDOMINAL EXAMINATION

Inspection:

  • Shape of the abdomen- flat
  • Umbilicus is central
  • No visible scars,pulsations, peristalsis, engorged veins


Palpation:

  • All the inspectory findings are confirmed.
  • No local rise of temperature 
  • Tenderness present over the epigastrium  and left hypochondrium region
  • Liver palpable 2cms below costal margin
  • Liver span: 11.5cm ( normal)
  • Spleen : not palpable 
  • Kidney : not palpable


Percussion:

  • No free fluid


Auscultation:

  • Bowel sounds heard 

2. RESPIRATORY SYSTEM - Normal vesicular breath sounds heard


3. CVS : S1 S2 heard , no added murmurs 


4. CNS : Higher function intact ,No motor and sensory deficit, Cranial nerves normal .




INVESTIGATIONS:


1. USG ABDOMEN:




2. SERUM LIPASE : increased to more than three times - 112 IU/L


3. SERUM AMYLASE-255 IU/L


4. HEMOGRAM:



5. RANDOM BLOOD SUGARS: 97mg/dl


6. RENAL FUNCTION TESTS:




7. LIVER FUNCTION TESTS:




8. BLOOD GROUPING: O+ve 


DIAGNOSIS


Pseudocyst of pancreas secondary to unresolved acute pancreatitis.


TREATMENT:

  1. Nil per oral (NPO)
  2. IV fluids RINGER LACTATE ,Normal saline 100 ml per hour
  3. Inj. TRAMADOL 100mg in 100ml NS IV BD
  4. Inj. PANTOP 40 mg IV OD
  5. Inj. OPTINEURIN 1 ampoule in 100ml NS IV OD


Psychiatric Medications 

  1. Tab . Lorazepam 2mg BD
  2. Tab . Benzothiamine100mg OD








Popular posts from this blog

A 75 YEAR OLD MALE WITH ALTERED SENSORIUM

-
Image
  A 75 YEAR OLD MALE WITH ALTERED SENSORIUM November 09, 2021 SOWJANYA REDDY PALAKURTHY 130 9Th semester  This is an online E-Log book to discuss our patient's de-identified data shared after taking his/her/Guardian's signed informed consent. Here, we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve these patient's clinical problems with collective current best evidence-based inputs. This E-log also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are welcome. 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. CASE: A 75 years old diabetic male came to casualty with c/o altered sensorium. CHIEF C
Read more

20 YEAR OLD FEMALE WITH ABDOMINAL PAIN AND VOMITING

-
Image
  A 20 YEAR OLD WITH ABDOMINAL PAIN AND VOMITING -29th March '2022 This is an online E log book to discuss our patient's de-identified health data shared after taking her guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.This E-log also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are welcome. SOWJANYA REDDY PALAKURTHY ROLL NO. : 130 9th Semester 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. CASE : 20 year old female patient, Nursing student by occupation h
Read more

GENERAL MEDICINE PREFINAL PAPER 1

-
Image
  LONG ANSWER QUESTIONS Q1 : Define Acute Kidney Injury. Etiology and Clinical features of AKI. Write a brief note on diagnosis and management.  A1 :  Q2 : What are types of Diabetes mellitus. Diagnosis of DM. Treatment of type 1 and type 2 DM. A2  :  SHORT ANSWER QUESTIONS Q3 : Write a brief note on pneumonia. A3 :  Q4 : Write a short note on cholelithiasis. A4 :  Q5 : Post streptococcal Glomerulonephritis. A4 :  Q6 : Write a short note on hypopituitarism. A6 :  Q7 : CML A7 :  Q8 : Hepatic encephalopathy and it's treatment? A8 :  VERY SHORT ANSWER QUESTIONS Q9 : Pulmonary Function tests. A9 :  Q10 : Indications of Dialysis. A10 :  Q11 : Beta Thalessemia? A11 :  Q12 : Disease modifying drugs in Rheumatoid arthritis?  A12 :  Q13 : Anti snake venom? A13 :  Q14 : What is SAAG? A14 :  Q15 : Crohns vs Ulcerative colitis? A15 :  Q16 : Causes of lymphedema? A16 : 
Read more