GENERAL MEDICINE E-log
K Aravind,9th sem,roll number 55
This elog depicts the patient -centered approach to learning . This is an online E log book recorded to discuss and comprehend our patients de-identified health data shared , after taking his /her /guardians signed informed consent . This elog also reflects patients centered learning portfolio.
CHEIF complaints;
40 yr old male patient who is daily wage labourer by occupation came to OPD with
of pain abdomen since 5 days associated with fever since 2 days .
History of presenting 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
.
Past history;
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 abdomen 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 examination;
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
Cvs examination
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 examination
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
Provional 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