General Medicine Blog-2

March 11, 2022

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/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 patient's clinical problems with collective current best evidence based inputs.

A 65 year old male patient, resident of Cherubhavi Gudem, Goldsmith by occupation came to our hospital with chief complaint of abdominal pain and chest pain.

Date of admission :- 04/03/2022

History of present illness:-
Patient was apparently asymptomatic 8 days back and developed abdominal pain and chest pain at midnight and pain increased gradually and had 2 episodes of vomitting, food as content.

History of past illness:-
Patient is not a known case of diabetes, hypertension, epilepsy and tb.

Personal history:-
Patient has normal eating habit with mixed diet.
Chronic alcholic(90ml / day since 10 years), no smoking.

Daily routine:-
Patient used to wake up at 6.00AM ,he used to fresh up, does some excercise and take breakfast at 9.00AM .Then he goes to his shop and does his work, takes lunch in between 1.00PM-2.00PM and dinner at 8.00PM and goes to bed by 9.00PM. Takes tea for about 4-5 times per day.

Family history:-
No significant family history.

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

Vitals:-
Temperature-99.6 F
Pulse rate- 88 bpm
RBS-104 mg/dl
BP -140/90 mmhg

Date:04/03/2022, Time:8.40AM
Date:04/03/2022, Time:10.50AM
Date:04/03/2022, Time:12.58PM
Date:05/03/2022, Time:7.10AM
Date:06/03/2022, Time:6.56AM
Investigations:-
X-ray erect abdomen
USG-Abdomen and pelvis
Troponin-1
Serum amylase
Serum lipase

Provisional diagnosis:-
Acute cholelithiasis, cholecystitis and pancreatitis.

Treatment:-
Inj. Pantop 40mg × IV × OD
Inj. Metrogyl 100ml × IV × TID
Inj. Zofer 4mg × IV × OD
Inj. Amikacin 500mg × IV × BD
Inj. Tramadol 1AMP in 100ml × IV × BD
Inj. Monocef 1gm × IV × BD
Tab. Udiliv 300mg × BD

Surgery required(cholecystectomy)

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