65 yr old female abdominal pain

THIS IS AN ONLINE E LOG BOOK TO DISCUSS Oassosciated UR 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 AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT .

         

GENERAL MEDICINE Pre final practical

Chief complaints:

A 65 yr old female patient house wife came to opd with chief complaints of abodminal pain for further treatment

HOPI

Pateint was apparently asymptomatic 45 days back and then developed abdominal Pain which is insidious in onset,  continuous in nature from epigastrium  radiating to left lumbar, pain relieved on leaning forward in sitting Position and on taking medicines, associated with vomitings which is non projectile non bilious, with food particles, 2 times per day for one week and associated with fever which is intermittent and increased in night time, for 3 days and relieved on medication, she had dizziness since 18 months, she had 3 episodes , before sleeping and after waking up from bed

She has no h/o chest pain, palpitations, sweating, tachypnea, sob

No  h/o constipation, diarrhoea, 

No h/o earpain , headache 

Past history

Not a known case of diabetes, hypertension, asthama, epilepsy, cva, cad, TB, THYROID diorders

18 months back she had similar complains of abdominal pain, vomitings , fever and dizziness

Personal history:

Diet: vegitarian

Appetite:normal

Sleep : normal

Bowel and bladder: regular

H/o no addiction, allergies

Family history: not significant

General examination: 

Pt is c/c/c moderately nourished and built

No pallor, icterus , cyanosis, clubbing, edema,lymphadenopathy

Vitals:

Bp : 130/70mmhg

Pr: 82bpm

Rr: 17

Grbs : 109mg/ dl

No postural hypotension

Rombergs sign : negative

Systemic examination:

Cvs : s1 s2 heard

Rs :  bae +, nvbs

P/ a : 

Inspection:

Shape-distended

Umblicus -normal shape, central in position

Movement with respiration present

Skin over abdomen with no scars

Palpation:

soft  tenderat epigastrium which spread to left lumbar

Auscultation: bowel sounds present

Cns : nfnd

Provisional diagnosis: acute pancreatitis

Investigation:

Treatement

IV fluid

Cefron 500mg

Zerodol

Domeperidone

Panto

Osce Questions:

Learning points:

. I’ve learnt the importance of a detailed personal history to come to the final diagnosis. 

-I’ve learnt the importance of helping make the patient at ease so they can be more vocal about their symptoms and routines. 

-I’ve learnt that we must always the patient how much of pain has subsided quantitatively [if he says the pain has subsided]. This is to have a clear idea of how effective the treatment has been working.

. I've learnt the concept of gallstone pancreatitis. 

. I've learnt What are the possible complications of gallstone pancreatitis?