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