30 year male with epigastric pain

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.


Complaints- 

c/o pain over epigastric region since 8:45pm yesterday.


HOPI- 

Pt was apparently asymptomatic 1 months back then developed pain over epigastric region, aggravated with spicy food intake and relieved on medication. 

Had similar complaints 3 days ago, relieved with medication. 

Now patient presented with pain over epigastric region since 8:45 pm, localised over the region, non radiating, tenderness present.

No SOB, palpitations, orthopnea, PND.

No c/o fever, vomitings, diarrhea.


Past history:

Not a k/c/o HTN, DM, thyroid disorders,epilepsy, CVA, asthma.


General examination-

Patient is C/C/C

BP-130/80mmhg

PR- 96 bpm

RR- 18cpm

GRBS- 104 mg/dl

Temp- 98.2F


SYSTEMIC EXAMINATION 


CVS- S1S2+,NO MURMURS

RS- BAE+,NVBS HEARD

P/A- SOFT,NON TENDER,BOWEL SOUNDS+

CNS- ORIENTED TO TIME,PLACE AND PERSON


Diagnosis- acute cholecystitis with cholelithiasis


Treatment-


  1. Normal diet allowed 
  2. Plenty of oral fluids
  3. Inj. Pan 40mg PO BD
  4. Inj. Tramadol 1amp in 100ml NS IV/ SOS
  5. Inj. Thiamine 200mg PO/TID
  6. Tab. TAXIM 200 mg PO/BD
  7. TAB. METROGYL 400mg PO/TID
  8. Monitor vitals 4th hourly 
  9. Inform SOS


CLINICAL IMAGES






 Investigations

























SUMMARY


Diagnosis- acute cholecystitis with cholelithiasis


Complaints- 

c/o pain over epigastric region since 8:45pm yesterday.


HOPI- 

Pt was apparently asymptomatic 1 months back then developed pain over epigastric region, aggravated with spicy food intake and relieved on medication. 

Had similar complaints 3 days ago, relieved with medication. 

Now patient presented with pain over epigastric region since 8:45 pm, localised over the region, non radiating, tenderness present.

No SOB, palpitations, orthopnea, PND.

No c/o fever, vomitings, diarrhea.


Past history:

Not a k/c/o HTN, DM, thyroid disorders,epilepsy, CVA, asthma.


General examination-

Patient is C/C/C

BP-130/80mmhg

PR- 96 bpm

RR- 18cpm

GRBS- 104 mg/dl

Temp- 98.2F


SYSTEMIC EXAMINATION 


CVS- S1S2+,NO MURMURS

RS- BAE+,NVBS HEARD

P/A- SOFT,NON TENDER,BOWEL SOUNDS+

CNS- ORIENTED TO TIME,PLACE AND PERSON


Treatment-

  1. Normal diet allowed 
  2. Plenty of oral fluids
  3. Inj. Pan 40mg PO BD
  4. Inj. Tramadol 1amp in 100ml NS IV/ SOS
  5. Inj. Thiamine 200mg PO/TID
  6. Tab. TAXIM 200 mg PO/BD
  7. TAB. METROGYL 400mg PO/TID
  8. Monitor vitals 4th hourly 
  9. Inform SOS


ADVICE AT DISCHARGE


Plenty of oral fluids

Tab Pan 40mg po/od/bbf

Tab thiamine 200mg po/bd

Tab taxim 200mg po/bd for 4 days

Tab metrogyl 400mg po/tid for 4 days

Review to surgery and medicine OPD after 1 week

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