42 yr old male with pain in epigastric region

A 42 yr old male patient came to casuality with
Chief complaint:-
  Abdominal pain in epigastrium since 3days.
 

  History of presenting illness:-
  Patient was apparently asympotamatic 5days back then he developed fever which was sudden in onset, intermittent in nature, high grade subsided after taking medication.it is associated with chills and rigor. 
  He developed epigastric pain 3 days back at Night for which he visited local hospital there Rmp has given injection but pain was not subsided , by morning pain got aggrevated for which patient came here. 
   Which was Sudden in onset, gradually progressive, non radiating , burning type. 
No H/o loose stools, nausea, vomiting. 
   
Past history :-
No similar complaints in the past. 
Not a known case of diabetes, hypertension, epilepsy, CHD. 
   
   Personal history :-
    Sleep -Adequate 
   Appetite -Reduced since 3days
   Bowel movements -regular
   Bladder movements -regular 
   Addictions -h/o alcohol intake since 10years     and smoking since 10years 
   No H/o allergies. 
  
 Family history :- 
No similar complaints in the family.

General Examination:-
Patient was conscious, coherent, cooperative well oriented to time place and person. 
No                                pallor,icterus,cynosis,clubbing,lymphadenopathy,edema.

Vitals:- 
Temperature: Afebrile
Bp:100/76
PR:78bpm
RR:17/min
Spo2:98%at RA 
 
Systemic examination :-
Abdomen- 
Inspection 
Shape - scaphoid 
Umbilicus - inverted
Abdominal movements - present
Stria marks - absent 
No distended veins
No visible peristalsis

Palpation :-
Gaurding or rigidity over abdomen.
 Liver and spleen are not palpable. 
Non tender, soft. 
 
Percussion :
No shifting dullness, fluid thrill. 
  
Auscultation :-
Bowel sounds not heard
CVS : S1 S2 heard no murmur
CNS : 
Conscious and normal speech
normal gait
crainal nerves are normal
sensory system is normal
motor system is normal
Respiratory system: Normal vesicular breath sounds .

Investigations :-
PROVISIONAL DIAGNOSIS:-
Viral pyrexia with
 thrombocytopenia .

TREATMENT:-
INJ.PANTOP 40 MG IV OD
INJ.OPTINEURON 100 MG IN 100 ML IV OD
TAB .DOLO 650 MG OD 
INJ.NEOMOL 1GM IV NS
SYP.SUCRALFATE 10 ML BD
IVF NS RL DNS @ 75 ml /hr.

Comments

Post a Comment

Popular posts from this blog

45 yr old male with CKD

Image
CASE BLOG  This is an online E-log to discuss our patient’s de-identified health data shared after taking hi/her/guardian’s 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 patients clinical problems with collective current best evidence based inputs.  This E-log also reflects my patient centered online learning portfolio and your valuable inputs on 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 competence in reading and comprehending clinical data including history, clinical findings and come up with diagnosis and treatment plan.  The patient and the attenders have been adequately informed about the documentation and privacy of the patient. No identifiers shall be revealed throughout this presentation. 45 yr old male with ckd Chief complaints::   A   45 year old ma
Read more

A 55yr old female complains of fever,decreased appetite since 1 month, Breathlessness since 1 week,vomitings and loose stools since 3 days.

Image
CHIEF COMPLAINTS: Pt complains of fever,decreased appetite since 1 month, Breathlessness since 1 week,vomitings and loose stools since 3 days .  HOPI: Patient was apparently asymptomatic 3 months back. Then she had multiple swellings in front of the left ear, for which she developed fever which was lowgrade, intermittent, no evening rise of temp, ass with decreased appetite since 1 month. She then had vomitings which was non bilious and non projectile, containing food particles. She had history of loose stools since 3 days, which is 4-5 episodes per day, watery in consistency.  Past history: K/c/o  Hypertension since 7 years.  7 yrs back she had c/o giddiness for which she went to hospital and was found to have HTN.  Personal history: Diet- mixed Appetite-decreased Bowel and Bladder movements- regular. Addictions- Allergies- none General examination : Patient is conscious, coherent and cooperative. Well oriented to time, place and person. Moderately built and moderately nourished. No p
Read more