A 40yr old male with pain in abdomen and fever associated with chills.

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CHIEF COMPLAINT:

 A 40 year old male who is a daily laborer by profession came to OPD with a chief complaint of :

-pain in the abdomen since 1 day.

-fever with chills since 1 day.

-nausea since 1 day.

HOPI:

Patient was apparently asymptomatic 15 years back, then he developed left sided pain(renal calculi) for which PCNL surgery was done.

4 months back patient developed yellowish discoloration of eyes and pain in abdomen for which he was admitted to the hospital and managed conservatively.

Now since 1 day patient complaints of pain in abdomen in right hypochondrium region which is  non-radiating , insidious in onset,  not associated with vomiting, associated with fever since 2 days which is  low grade, intermittent type and relieves with medication.

DAILY ROUTINE:

He is a daily laborer by profession, wakes up at 6am, eats chapatti in breakfast with curry and goes to work. He take his lunch on work complete till 2pm , return back to home till 7pm and eat dinner. he occasionally drink late night and sometimes oversleep ad get late for work so miss the work opportunity.

PAST HISTORY:

K/C/O DM since 6 months on Tab Glycichek (metformin500mg+glimipride1mg+ voglibose 0.2mg)

N/K/C/O HTN ASTHMA CAD

PERSONAL HISTORY:

Married

Occupation: daily laborer

Diet: mixed

Bowels: regular

Micturition: normal

No known allergies

Habits: occasional alcoholic

FAMILY HISTORY:

There is no similar complaints seen in his family.

GENERAL EXAMINATION:

On examination patient is conscious, coherent and cooperative and well oriented to time, place and person and consent was taken to examine her.

Pallor: absent

Icterus: absent

Cyanosis: -

Clubbing: -

Lymphadenopathy: absent

Pedal edema: absent

Dehydration: absent

VITALS:

Temp: 98.4F

BP:110/70 mm Hg

PR: 80bpm

RR: 16 cycles/min

SPO2: 96%

SYSTEMIC EXAMINATION:

CVS:

s1 and s2 sounds +

no thrills and no murmurs heard

RS:

Dyspnea: no

Wheeze: no

position of trachea: central

vesicular breath sounds heard

ABDOMEN:

shape of abdomen: scaphoid

tenderness at right hypochondrium region

 no organomegaly detected

 (ABDOMINAL QUADRANTS EXAMINATION)

CNS:

conscious

normal speech 

normal gait

cranial nerves are intact

sensory system normal 

motor system normal

Gait- normal

REFLEXES:  BICEPS  TRICEPS  SUPINATOR  KNEE   ANKLE

RIGHT           2+             2+            2+                   2+            2+

LEFT             2+             2+            2+                   2+            2+

Cerebellar signs:

-finger -nose -in- coordination: absent

-knee-heel-in-coordination: absent

INVESTIGATIONS:

PROTHROMBIN TIME:

HEMOGRAM:

 

COMPLETE URINE EXAMINATION:

APTT:

BLOOD SUGAR-FASTING:

POST LUNCH BLOOD SUGAR:

RFT:

LFT:

SERUM AMYLASE:

SERUM LIPASE:

CT SCAN ABDOMEN AND PELVIS:

Chest X Ray:

PREVIOUS HOSPITAL RECORDS:

PROVISIONAL DIAGNOSIS:

Acute pancreatitis secondary to cholecystitis.

TREATMENT PLAN:

23.11.22

NBM from 12:00 am

IVF : 2 UNITS NS @100ML

         2 UNITS RL @100ML

INJ PAN 40 MG IV-OD

INJ ZOFER 4MG IV SOS

INJ TRAEMEDOL 1AMP IV IN 100ML NS BD

TAB DOLO650 PO SOS

MONITORING BP/PR/RR/TEMP AND GRBS CHARTING 4RTH HORLY  

24.11.22

IVF : 2 UNITS NS @100ML

         2 UNITS RL @100ML

INJ PAN 40 MG IV-OD

INJ ZOFER 4MG IV SOS

INJ TRAEMEDOL 1AMP IV IN 100ML NS BD

TAB METFORMIN+GLIMIPRIDE 500MG PO/OD

INJ HAI SC TID

INJ. VIT K 10MG IN 100 ML NS

MONITORING BP/PR/RR/TEMP AND GRBS CHARTING 4RTH HORLY  

25.11.22

IVF : 2 UNITS NS @100ML

         2 UNITS RL @100ML

INJ PAN 40 MG IV-OD

INJ ZOFER 4MG IV SOS

INJ TRAEMEDOL 1AMP IV IN 100ML NS BD

TAB METFORMIN+GLIMIPRIDE 500MG PO/OD

INJ HAI SC TID

INJ. VIT K 10MG IN 100 ML NS

MONITORING BP/PR/RR/TEMP AND GRBS CHARTING 4RTH HORLY  

26.11.22

IVF : 2 UNITS NS@100ML  

         2 UNITS RL @100ML

INJ PAN 40 MG IV-OD

INJ ZOFER 4MG IV SOS

INJ TRAEMEDOL 1AMP IV IN 100ML NS BD

TAB METFORMIN+GLIMIPRIDE 500MG PO/OD

INJ. THIAMINE 100MG IN 100 ML NS

MONITORING BP/PR/RR/TEMP AND GRBS CHARTING 4RTH HORLY