Sridevi e-log

Hello everyone..! I am SrideviTripuraneni,an intern posted in medicine department and one of the most important terms of getting internship completion is to complete my log book with my online log of what I learn during the course of my duties.

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 protfolio and your valuable inputs on comment box is welcomed.

Here is the case i have seen:

A 39 year old male came to the hospital with chief complaints of pain abdomen since 3 days, nausea since 3days

History of present illness:

Patient was apparently symptomatic 3 days back then he attended a party where after taking food he developed pain in epigastric region,burning type ,non radiating ,aggrevated on drinking water and taking solids.

Assosciated with nausea,vomitings,loose stools

-vomitings: 4 episodes,4 days back,bilious type,non projectile,contains food particles, no haematemesis

-loose stools: 3 episodes ,3days back,normal volume and watery in consistency,no bulky stools ,no melena,no blood or mucous in stools,no foul smelling

-compalins of constipation since 3 days ,flatus present

-No history of fever ,burning micturation

Past history:

K/C/O acute pancreatitis-1st episode:2years back ,2nd episode:1 1/2 years back

Not a k/c/o hypertension,diabtes,copd,asthma,tb

Personal history:

He has mixed diet with a normal appetite,adequate sleep,regular bladder movements,constipation since 3days

Alcoholic 2years back -used to take 90ml of whiskey per day

General examination :

Pt is conscious,coherent and cooperative,moderately built and nourished

Vitals-afebrile,BP-130/80mmhg,PR-82bpm,RR-17cpm

No pallor,icterus,cyanosis,clubbing,pedal edema,lymphadenopathy

P/A-

Soft ,mild tenderness in epigastric region,no rise in temperature,no guarding,no rigidity,no organomegy,hernial orifices are free,bowel sounds present

CVS-

S1 S2 heard, no murmurs

RS-

Shape-normal,NVBS heard,trachea midline, no wheeze,no added sounds

CNS-

Higher mental functions:normal

Motor system:intact

Sensory system:intact

Cranial nerve examination:normal

Investigations:

X ray abdomen PA view

ECG

USG abdomen

Diagnosis:

Acute Gastroentritis

K/C/O pancreatitis

Treatment:

1.plenty of oral fluids

2.Tab.cefixime 500mg BD

3.Inj..pantop 40mg BD

4.Inj. Zofer 4 mg SOS

5.Tab.buscopan 10mg SOS

2nd admission after one month:

Pt came with complains of epigastric pain since 4 days ,constipation since 4 days

History of present illness:

Pt was apparently asymptotic 4 days back then developed epigastric pain which is burning type ,radiating to back, aggrevated on taking food (solids and liquids) and relieved by medication,constipation since 4days

Vomitings since 1day, 2episodes , bilious ,non projectile,contains food particles

No history of fever ,nausea,vomitings,burning micturition

Past history:

Known case of acute pancreatitis 2 yrs back

Not a k/c/o diabetes,hypertension,asthma,copd,tb

Personal history:

He has mixed diet with a normal appetite,adequate sleep,regular bladder movements,constipation since 4 days

Alcoholic 2years back -used to take 90ml of whiskey per day

General examination :

Pt is conscious,coherent and cooperative,moderately built and nourished

Vitals-afebrile,BP-150/100mmhg,PR-90bpmRR-22cpm

Grbs-126mg/dl

Spo2-99%@room air