Med. e-log case 4

41yr old male patient came to casuality 

Chief complaints of  - high coloured urine since 2 years

 pain abdomen since 1 week

patient was apparently asymptomatic 2 yrs back and then he developed high coloured urine for which he went to a private hospital  and was told that he had  ureteric calculi(no medical records). Later , he had on and off episodes of high coloured urine weekly twice .He was diagnosed with hypertension in 2019 for which he took medication only for 1 week and then when he went for regular checkup in 2020 again as his BP was high and prescribed medication which he used only for 1 week.

- Pain abdomen since 1 week which was Diffuse, continuous, squeezing type,aggravated on eating food.

 No H/o loose stools and vomitings, No H/o fever .

He had similar episodes in the past and taken treatment for the same 6 months  ago

Past history 

k/C/O HTN since 2Years - not on any medication

Not a k/c/o DM, Epilepsy, Asthma, thyroid disorder 

Cholecystectomy was done 1 year back 

Personal history 

Alcoholic since 7 years[120/ml daily since 1 year]

H/o smoking 10 years back 

Examination - 

pt is conscious coherent cooperative 

No signs of pallor, cyanosis , clubbing ,lymphadenopathy and pedal edema

vitals - 

Temp- Afebrile 

PR-110bpm

BP-180/120mmhg

GRBS-150mg/dl

spo2-98%at RA

Systemic Examination 

CVs-s1,s2 +

RS-BAE+

P/A - 

No visible peristalsis

All quadrants moving equally with respiration

On Palpation 

No local rise of temperature

Tenderness present in the epigastrium , right and left hypochondrium

No rigidity

Guarding present in epigastrium and right hypochondrium

Provisional Diagnosis 

ACUTE PANCREATITIS

Investigations

ON THE DAY OF ADMISSION

Treatment 

1.IVF @100ml/hr

2.INJ PAN 40 MG IV/OD

3 INJ ZOFER 4MG/IV/ OD 

4.INJ OPTINEURON IV/OD

5.INJ TRAMADOL 1 AMP IN 100ml NS/IV/SOS

6.RYLES TUBE INSERTION

DAY 1

1.IVF(NS DNS)@100ML/HR

2.INJ PAN 40 MG IV/OD

3 INJ ZOFER 4MG/IV/ OD 

4.INJ OPTINEURON IV/OD

5.INJ TRAMADOL 1 AMP IN 100ml NS/IV/SOS

6.RYLES TUBE INSERTION

DAY2

1.IVF(NS DNS)@100ML/HR

2.INJ PAN 40 MG IV/OD

3 INJ ZOFER 4MG/IV/ OD 

4.INJ OPTINEURON IV/OD

5.INJ TRAMADOL 1 AMP IN 100ML NS/IV/SOS

6.SYP CREMAFFIN PLUS 15ML/PO/TID

DAY 3

Pain subsided

1)ORAL FLUIDS

2.INJ PAN 40 MG IV/OD

3 INJ ZOFER 4MG/IV/ OD 

4.INJ OPTINEURON IV/OD

5.INJ TRAMADOL 1 AMP IN 100ML NS/IV/SOS

6.SYP CREMAFFIN PLUS 15ML/PO/TID

DAY 4

S-C/o high coloured urine since 2 years

O-On examination 

Bp-160/90mm hg

PR-88bpm

RR-16cpm

CUE- RBC- plenty

         Albumin +++

         Pus cells -plenty

A - acute pancreatitis with urinary tract 

P- TREATMENT GIVEN

1)ORAL FLUIDS

2.INJ PAN 40 MG IV/OD

3 INJ ZOFER 4MG/IV/ OD 

4.INJ OPTINEURON IV/OD

5.INJ TRAMADOL 1 AMP IN 100ML NS/IV/SOS

6.SYP CREMAFFIN PLUS 15ML/PO/TID

7)SYP CITRALKA 15ML PO/BD

8) TAB NITROFURANTOIN 100MG/PO/BD

9)TAB TELMA 40MG /PO/OD

DAY 5

BURNING MICTURITION SLIGHTLY DECREASED AND HEMATURIA PRESENT

acute pancreatitis with urinary tract 

P- TREATMENT GIVEN

1)ORAL FLUIDS

2.INJ PAN 40 MG IV/OD

3 INJ ZOFER 4MG/IV/ OD 

4.INJ OPTINEURON IV/OD

5.INJ TRAMADOL 1 AMP IN 100ML NS/IV/SOS

6.SYP CREMAFFIN PLUS 15ML/PO/TID

7)SYP CITRALKA 15ML PO/BD

8) TAB NITROFURANTOIN 100MG/PO/BD

9)TAB TELMA 40MG/PO/OD

Diagnosis- ACUTE PANCREATITIS (RESOLVED) WITH CHRONIC GLOMERULONEPHRITIS 

 

Med. e-log case 3

A 54year old male patient Came to the OPD 

Chief complaints - cough with expectoration since 6 days and low-grade fever since 6 days.

Patient was apparently asymptomatic 3yrs back and then he developed shortness of breath initially of GRADE II which progressed to grade IV at present

B/L pedal oedema of pitting type since 18 months

PND since 6months. 

Palpitations since 6 months.

Orthopnea Since 3months.

 Nocturia since 2months 

6 days back he developed cough with expectoration of insidious onset along with low grade fever which is intermittent 

No H/O chest pain, haemoptysis, vomiting, abdominal pain, Burning micturition and No h/o increased frequency, urgency.

History of TB 16 years back for which he was treated.

Not a k/c/o DM/HTN/Asthma/Epilepsy/CAD

Mixed diet, loss of appetite, regular bowel & bladder movements.

Consumption of 180 to 360 ML of alcohol daily for the past 10 years.

No known allergies

General examination- 

Patient is conscious, coherent, cooperative.

Pallor +, B/L pedal edema +

No signs of icterus, cyanosis, clubbing, generalised lymphadenopathy 

Vitals-

Bp: 110/60 mm hg

PR:118 bpm

RR:16cpm

Spo2:82% @ RA - 100% @ 4 lit O2

Temp : Afebrile

Cardio Vascular System - 

Jvp raised

Precordial pulsations +

RV type apex

Epigastric pulsations +

Palpable P2 + and parasternal haeve of Grade III

s1 s2 + , no murmurs

Respiratory system - 

Dyspnea present

Centrally positioned trachea

Reduced chest movement on left side

BAE+ Decreased BS on Left side

NVBS heard 

Crepts heard at inter-scapular, infra scapular areas 

ABDOMEN - 

Soft, non-tender, bowel sounds heard.

CNS - 

No abnormality detected.

0

Provisional diagnosis - 

Heart Failure with Mid range Ejection Fraction secondary to ? Old pulmonary TB (cor pulmonale)

Treatment - 

TAB.LASIX 40mg BD

O2 Supplementation @ 4 lit

BP/PR/Temp/ SpO2 monitering 4th hourly 

Med. e-log case 2

33 year old female with recurrent oral ulcers 

Farmer by occupation ,

Chief complaints of recurrent oral lesions since 10 months 

HOPI - patient was apparently asymptomatic 10 months back and then developed a small red coloured lesions on the left side of the oral cavity which was painful and in the following days , the new lesions are developing .

She took some treatment and no fresh lesions are seen up to 1 month. But after a month again new lesions are seen 

Aggravating Factors - Spicy foods 

Relieving factors - Medications.

 PAST HISTORY - No h/o such lesions in the past 

NOT A KNOWN CASE OF HTN, DM, BA, TB, EPILEPSY . 

NO OTHER KNOWN COMORBIDITES .

GENERAL EXAMINATION : PT IS C/C/C ORIENTED TO TIME , PLACE AND PERSON .

NO PALLOR , CYANOSIS, LYMPHADENOPATHY , CLUBBING , ICTERUS , EDEMA .

 ON LOCAL EXAMINATION -

MULTIPLE LESIONS OVER THE BUCCAL MUCOSA AND HARD PALATE and  WHITE COATED TONGUE .

SYSTEMIC EXAMINATION - 

CNS : GCS 15\15 , NO ABNORMALITY DETECTED.

CVS - S1,S2 HEARD , NO MURMURS .

RS : NVBS HEARD , NO ADDED SOUNDS .

P/S : VAGINAL MUCOSA  WITH CURDY WHITE DISCHARGE .

Investigations - 

SERUM ELECTROPLYTES : Na : 137 m Eq /L , K : 4.7 mEq /L , Cl : 107 mEq /L .

CUE : ALB : + , SUGARS : NIL , PUS CELLS : 3-4 , EPITHELIAL CASTS : 2-3.

HIV : NON REACTIVE 

Provisional diagnosis : 

RECURRENT ERYTHEMA MULTIFORME  SECONDARY TO HSV

? CHRONIC APHTHOUS ULCERS 

? BECHETS DISEASE

? CHRONIC CANDIDIASIS.

Treatment given initially - 

1] DNS  -3

2] ORS SACHETS

3] INJ. PAN -D OD BBF

4] WARM SALINE GARGLES

5] INJ. PCM IV SOS

6] WATCH FOR BREATHING DIFFICULTY

7] PLENTY OF ORAL FLUIDS

8] TAB. ACELO-P  BD

9] TAB. OFLOX -OZ 200 MG BD

10]  SYP. CREMAFFIN 15 ML H/S

11]  OINT. ANOBLISS  L/A ANAL REGION

 

Treatment given at present - 

1) IV fluid NS @ 50 ml/hr

2) Inj.TRAMADOL 1 ampule in 100ml NS IV over 30min

3) Syp MUCAINE GEL 10ml/ PO / TID

PRESENT CONDITION : The patient had pain relief after medication