Name: K.Sannith Reddy
Roll no. 65
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.
Following is the view of my case :
CHEIF COMPLAINTS:
15 year old male student resident of Nalgonda complains of pain abdomen since yesterday
Vomitings Since Yesterday.
HOPI:
Patient was apparently asymptomatic until 2 days ago then he had sudden onset of epigastric pain since yesterday morning non-radiating.
5 Episodes of vomitings since yesterday morning
first episode after one hour of lunch, food as content
Vomitings are green in colour bilious ,projectile
Second episode is after 15 mins of drinking milk
Third episode after 20 mins of drinking Pulpy orange.
fourth episode after having grapes, last episode yesterday evening
No c/o Fever, Headache; Giddiness
NO c/o chest pain,sweating, palpitations,orthopnea,pnd,cough,sob
NO c/o burning micturition,loose stools,nausea
No h/o DM,HTN,TB,ASTHMA,CVA,CAD
PERSONAL HISTORY
Diet mixed
appetite normal
sleep adequate
no addictions
bladder and bowel movements regular
NO SIGNIFICANT FAMILY HISTORY
GENERAL EXAMINATION:
Pt is c/c/c
NO pallor,icterus,cyanosis,clubbing, lymphadenopathy, edema
vitals:
BP-110/70mm hg
pr- 75bpm
RR 17cpm
Spo2 -98% ra
grbs 125mg/dl
SYSTEMIC EXAMINATION:
CVS S1,S2 heard ,no murmurs
RS- BAE + ,NVBS
P/A soft,nontender
CNS: NFND
INVESTIGATIONS:
DIAGNOSIS:
?ACUTE PANCREATITIS
TREATMENT:
NBM Till further orders
IV FLUIDS NS and DNS @100 ML /HR IV
INJ TRAMADOL 1 AMP IN 100 ML NS IV TID
INJ ZOFER 4MG IV STAT (NEXT SOS)
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