Gm blog series 27/4/23

CHEIF COMPLAINTS

 42year male Supervisor in petrol bunk came with c/o (on 24-4-2023)

1)Vomiting - 3episodes in the night(8pm on 23-4-2023)

2)Pain abdomen-Diffuse(in the morning 4am)

HISTORY OF PRESENTING COMPLAINTS :
   Patient was apparently asymptomatic 3 days back and had vomitings in night.
Patient takes 90ml/day IB brand liquor.on 23-4-2023 at 8pm patient had vomiting 3 episodes non bilious, non projectile, contains food particles,non foul smelling,non blood tinged.Associated with diffuse abdominal pain, not relieving on bending forward.As the intensity of pain increased in the morning, he came to our causality at 4am.

No history of any fever,loose stools,chest pain, palpitation,cough,constipation,obstipation

PAST HISTORY

K/C/O DM2(on metformin 500mg) & HTN(On Amlodipine 5mg).

PERSONAL HISTORY

Mixed diet

Regular bowel and bladder habits

Alcoholic since 23years(takes 90ml/day -IB brand liquor)

Daily routine : wakes at 8:00am,bathe and eat tiffin,9am goes to petrol bunk.supervises the bill collections till 6:00pm and return home with 90ml IB brand liquor.Drinks at 8:00pm,Eat dinner at 9:30pm and goes to sleep by 10:00pm

FAMILY HISTORY

Mother expired due to cancer and Father expired Post CVA sequle.Brother expired bcz of ?liver cirrhosis

MEDICAL HISTORY

Tab Metformin 500mg once daily at 8:00am

Tab Amlodipine 5mg once daily at 8:00am

GENERAL EXAMINATION

Patient is conscious, coherent,co-operative.Moderately built and Moderately nourished.

Blood pressure-130/70mmhg,right arm, supine position

Pulse-90/min,regular rythm,normal volume.

Respiratory rate-20/min,thoraco abdominal

Temperature-98 F

Spo2-98% on room air

Grbs-175mg/dl

Icterus+

No pallor,clubbing,cyanosis,lymphedenopathy,edema of legs

No raised JVP

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM :

-Elliptical & bilaterally symmetrical chest

-No visible pulsations/engorged veins on the chest

-Apex beat seen in 5th intercostal space medial to mid clavicular line

-S1 S2 heard

-No murmurs

RESPIRATORY SYSTEM:

  Upper respiratory tract-normal

  Lower respiratory tract :

-Trachea is central

-Movements are equal on both sides

-On percussion resonant on all areas

-Bilateral air entry equal

-Normal vesicular breath sounds heard

-No added sounds

-Vocal resonance equal on both sides in all areas

CENTRAL NERVOUS SYSTEM :

-Higher mental functions intact

-Cranial nerves - intact

-Sensory system-normal

-Motor system -normal


PER ABDOMEN








-Scaphoid

-No visible pulsations/engorged veins/sinuses

-Soft,non tender, no guarding and rigidity,organomegaly +(Liverspan-18cm)

-Bowel sounds heard

PROVISIONAL DIAGNOSIS

Pain abdomen secondary to ?Alcoholic bowel dysfunction ?Acute Pancreatitis ?Acute cholecystitis

k/c/o DM2 & HTN(since 2years)

INVESTIGATIONS






FINAL DIAGNOSIS

Alcoholic liver disease,Hyper triglyceridemia,Thrombocytopenia.


Popular posts from this blog

Gm case 13/4/23

Image
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have 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 diagnosis and treatment plan.   A 32yr old male patient who is a resident of miryalaguda , came with, Chief complaints: of: Fever since 7 days  Pain abdomen since 7 days . History of present illness: Patient was apparently asymptomatic 7 days back then he had fever which is sudden in onset,high grade and with chills and rigors, with body aches, and  releived by taking medication. Pain abdomen since 7 days in right hypochondriac,right lumbar, umbilical region, which is needle pricking type of pain , aggrevated during expiration. Not relieved on medication . No h/o chest pain,sob, palpitations No h/o nause
Read more

OSCE AND LEARNING POINTS. 5/12/23 prefinals

OSCE AND LEARNING POINTS OF A CASE OF CEREBRO VASCULAR ACCIDENT. 5/12/23 OSCE: 1.𝐖𝐡𝐚𝐭 𝐚𝐫𝐞 𝐭𝐡𝐞 𝐬𝐞𝐧𝐬𝐨𝐫𝐲 𝐚𝐧𝐝 𝐦𝐨𝐭𝐨𝐫 𝐚𝐫𝐞𝐚𝐬 𝐬𝐮𝐩𝐥𝐥𝐢𝐞𝐝 𝐛𝐲 𝐌𝐂𝐀 𝐚𝐧𝐝 𝐰𝐡𝐢𝐜𝐡 𝐚𝐫𝐞 𝐚𝐟𝐟𝐞𝐜𝐭𝐞𝐝 𝐢𝐧 𝐭𝐡𝐢𝐬 𝐜𝐨𝐧𝐝𝐢𝐭𝐢𝐨𝐧?  • The middle cerebral artery (MCA) primarily supplies blood to various regions of the cerebral cortex. Sensory and motor areas supplied by the MCA include parts of the face, upper and lower limbs, and areas involved in sensory and motor functions. The specific regions can vary among individuals, but generally, the MCA contributes to the blood supply of the lateral convexity of the cerebral hemisphere. This includes the precentral gyrus (primary motor cortex) and the postcentral gyrus (primary somatosensory cortex). Damage to the MCA can lead to motor and sensory deficits on the contralateral side of the body. 2. CLINICALLY WHERE DO YOU LOCALIZE LOSS OF SPEECH IN A PATIENT? Ans: In clinical terms, the localization of speech loss in a pat
Read more

Gm blog series -(26/4/23)

Image
This is an online elog documenting de-identified patient health data after taking his signed consent to enforce a greater patient centered learning.  The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever. CASE DISCUSSION  CHIEF COMPLAINTS AND HOPI: A 56 year old male patient who is a resident of koilagudem (nalgonda district)who is a daily wage labourer by occupation brought to the casualty in unresponsive state at 1:30 Am .patient was found drowsy from 1 pm on 25/04/2023 And suddenly developed seizure like activity associated with slurring of speech,uprolling of eyeballs,stiffness of all four limbs, Associated with involuntary defecation and micturition and found unresponsive.  No h/o fever ,cough. No h/o neck stiffness and projectile vomitings.  No h/o generalised weakness ,tingling,numbness. No h/o head trauma. Cheif complaints of swellings with discharge not associated with pain on the left forearm. Histor
Read more