03 Sai Tarun (july 24 2021)

 GENERAL MEDICINE CASE (25-07-21)


Welcome and greetings to every one who are visiting my blog. This is A.Sai Tarun of 3rd semester. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.


Introduction

A 20 year old male who has fever from 2 days brought to the OPD. Patient has chief complaints of epigastric discomfort , nausea, chest tightness , yellowish discolouration of eyes and urine and loss of appetite all the above from 4 days. 
Patient was apparently asymptomatic for 6 days back then had sudden onset of fever , low grade hot.

HISTORY OF PRESENT ILLNESS

•Pain in abdomen
•cold
•cough
•loss of appetite
•vomitings
•loose stools
•chills and rigor

•He then went to RMP and took medicines and the fever has been subsided.
Then yellowish discolouration of eyes and urine appeared.


HISTORY OF PAST ILLNESS 

•NO H/O Malena , mucus/blood in stools, previous abdominal surgeries.

PERSONAL HISTORY

•Mixed diet

•Loss of appetite

•Sleep adequate

•Bowel and Bladder movements regular

TREATMENT HISTORY 

 •No H/O any surgical procedures / Long term treatment.

FAMILY HISTORY 

•Not significant

GENERAL EXAMINATION

•Patient is conscious, coherent and cooperative

•Moderately built and Moderately nourished

•No signs of - Pallor

                       Cyanosis

                       Clubbing

•Icterus present

VITALS

•Temperature - Afebrile

•PR - 80 bpm

•BP - 110/70 mmHg


SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

•S1, S2 heard

•No murmurs

RESPIRATORY SYSTEM:

•NVBS heard

CENTRAL NERVOUS SYSTEM:

•Intact

•No focal defect

•No abnormality detected

INVESTIGATIONS 

25/07/21


APTT test



Prothrombin time



Pathology



24/07/21

Complete blood picture



Ultrasound



Complete urine examination











PROVISIONAL DIAGNOSIS

- Acute Cholecystitis with Gall Bladder Sludge

TREATMENT 

24/07/21

INJ Pantop 20mg in 500ml NS IV
T Pantop 40mg po/OD
INJ optineuron 1AMP IN 100ml NS IV/OD
INJ zofa 4mg IV/BD
SYP Cyproheptadine 10ml PO/ID
BP/PR/TEMP  4th hourly
GRBS 12th hourly

25/07/21

INJ OPTINEURON 1 AMP in 100ML NS IV/OD
IVF NS and DNS at 50ml/hr
INJ PANTOP 40mg IV/OD 
INJ ZOFA 4mg IV/SOS
BP/PR/TEMP  12th hourly
GRBS 12th hourly








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