C/O FEVER SINCE 15 DAYS ABDOMINAL PAIN SINCCE 15 DAYS VOMITINGS SINCE 15 DAYS
Case History and Clinical Findings
C/O FEVER SINCE 15 DAYS
ABDOMINAL PAIN SINCCE 15 DAYS
VOMITINGS SINCE 15 DAYS
HOPI :
PATIENT WAS APPARENTLY ASYMTOMATIC 3 MONTHS BACK THEN SHE HAD BURNING MICTURAION, FROTHY URINE,URGENCY,POLYURIA,NOCTURIA
NO H/O POLYDIPSIA
COMPLAINTS OF FEVER SINCE 15 DAYS, INTERMITTENT, LOW GRADE,ASSOCIATED WITH CHILLS AND RIGORS, RELIEVED BY TAKING MEDICATION
EPIGASTRIC PAIN SINCE 15 DAS, SQUEEZING TYPE, TENDERNESS PRESENT, NO GUARDING, NO RIGIDITY, ASSOCISTED WITH VOMITINGS,FOOD AS CONTENT, NON PROJECTILE,NON BILIOUS,NON FOUL SMELLING, 3-4 EPISODE OF BLACK COLOURED VOMITTINGS
NO LOOSE STOOLS, NO CHEST PAIN,PALPITATIONS, COUGH, COLD
PAST HISTORY ;
H/O OF SPLIT SKIN GRAFT FOR RIGHT DIABETIC FOOT FOR 4 YEARS BACK
H/O LEFT BELOW KNWW AMPUTATION 1 YEAR BACK
H/O HYSTERECTOMY
K/C/O TB 5 YEARS BACK, DM SINCE 20 YEARS ON MIXTARD INSULIN 20 UNITS, HYPERTENSION SINCE 1 YEAR ON TAB TELMA 40 AND AMLO 5MG PO/OD,
H/O BLOOD TRANSFUSION OF 8 UNITS
PERSONAL HISTORY
LOSS OF APPETITE SINCE 1 MONTH
FAMILY HISTORY ;
MOTHER K/C/O DM 2
GERNERAL EXAMINATION
O/E: PATIENT IS CONSCIOUS AND COHERENT
NO SIGNS OF PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY
VITALS:-
TEMP:96.8F
PR:82 BPM
RR:42 CPM
BP:140/80 MM HG
GRBS: 199 MG/DL
CVS: S1 S2 HEARD , NO MURMURS
RS: BAE PRESENT , NO ADDED SOUNDS
P/A: SOFT, NON TENDER
CNS: NFND
Provisional Diagnosis:-
ACUTE PANCREATITIS SECONDARY TO CHOLELITHIASIS
MULTIPLE GASTRIC AND DUODENAL ULCER
HYPERKALEMIA resolved SECONDARY TO AKI
HYPONATREMIA
K/C/O DM II 20 YEARS
K/C/O HTN 1 YEAR
K/C/O TB
Investigation:-
HEMOGRAM
27/03/23
HB 8.9
TLC 19300
PLATELET
28/03/23
HB 7.6
TLC 13900
PCV 2.88
RBC 2.88
PLATELET
30/03/23
HB 6.8
TLC 12100
RBC 2.57
PLATELET
31/03/23
HB 6.5
TLC 9800
RBC 25
COUNT 5.48
COUNT 4.2
COUNT 4.18
PLATEL;ET COUNT 3.93
01/04/23
HB 6.8
TLC 9900
RBC 2.63
PLATELET COUNT 4.0
02/04//23
HB 7.4
TLC 11300
PCV 24
RBC 2.83
PLATELET COUNT 4.16
ULTRASOUND
GALL BLADDER ; 4MM CALCULUS NOTED
RIGHT KIDNEY; 4MM CALCULUS NOTED IN THE UPPER POLE
ECHOTEXTURE INCREASED
LEFT KIDNEY ; FEW CALCULI NOTED
LARGEST SIZE 8MM CALCULUS NOTED IN THE MIDPOLE
ECHOTEXTURE INCREASED
FINAL IMPRESSION ; CHOLELITHIASIS
BILATERAL RENAL CALICULI
BILATERAL GRADE 1
DOPPLER ;
EF 45 PERCENT
IVC 0.77CM COLLAPSING
RVSP 30MM Hg
TRIVIAL AR/MR/TR
RWMA LAD HYPOKINETIC NO AS/MS
MODERATE LV DYSFUNCTION
DIASTOLIC DYSFUNCTION,NO PAH/PH
UPPER GI ENDOSCOPY - MILD DISTAL ESOPHAGITIS , DEEP EXCAVATED ULCER ABOUT 2X2 CM WITH ACID HEMATIN AT BASE , ANOTHER TWO SMALL ULCER , MULTIPLE GASTRODUODENAL ULCERS WITH SRH , NSAID INDUCED
NCCT ABDOMEN:
Treatment Given:-
1. IV FLUIDS NS,1DNS,1RL 2 75ML
2.INJ MONOCEF 1GM IV/BD
3.INJ TRAMADOL
4. INJ PAN 80MG IN 100ML NS IV/BD
5.INJ ZOFER 4MG IV/SOS
6. INJ LASIX 40MG IV/OD
7.T.CINOD 10MG PO/OD
8.T.MET-XL 25MG PO/OD
9. T.ECOSPORIN AV 75/10 PO H/S
10. SYP. SUCRALATE 10ML PO/TID
Advice at Discharge:-
INJ HUMAN ACTRAPID INSULIN 10 UNITS S/C TID BBF
TAB AGUMENTIN 625MG PO/TID X 5 DAYS
TAB ULTRACET PO/OD SOSX 5 DAYS
TAB PAN 40MG PO/ODX 5 DAYS
TAB ZOFER 4MG PO/SOS X 5 DAYS
TAB LASIX 40MG PO/OD
T.CINOD 10MG PO/OD
T.ECOSPORIN AV 75/10 PO H/S
SYP. SUCRALATE 10ML PO/TID 10 MIN BEFORE FOOD
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