Long case

 Welcome and greetings to every one who are visiting my blog. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan. 

A 55 year old male patient shepherd by occupation  came to the opd with the chief complaints of burns over the face due to oil spillage and pain in the abdomen since two days 

Date of admission:14/01/2023

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic  3years back ,then he had fever  associated with body aches for which he went to a hospital where he was diagnosed with diabetes mellitus and was on oral hypoglycemics since then .2days back,he underwent trauma ( burns -oil spillage as he had stepped on fire camp)under the effect of alcohol (90ml that morning) which caused  superficial burns over the face  and blisters over the right shoulder, pain in epigastric region which is squeezing in nature,non radiating,not associated with nausea,vomiting.

HISTORY OF PAST ILLNESS:

Patient is a known case of diabetes (since 3years  for which he is on vildagliptin and metformin medication)

Not a known case of  hypertension, asthama, epilepsy, tuberculosis,CAD 

No history of previous surgery 

FAMILY HISTORY:No significant family history 

PERSONAL HISTORY:

Married,2girl children and a male child

Appetite:normal

Diet: mixed

Sleep: adequate

Bowel and bladder: normal

Addictions: alcoholic(90ml per day) since 30years,smoking (3-4cigars per day)

Drug history:not allergic to known drugs 

GENERAL EXAMINATION:

Patient was concious coherent cooperative and well oriented to time place and person

No pallor, cyanosis, clubbing, icterus, bilateral pedal edema, generalized lymphadenopathy 

VITALS:Built:moderate

Temperature: afebrile 

Pulse rate:78bpm

Bp:140/80 mm/hg

Respiratory rate:16 cpm

SpO2:98

SYSTEMIC EXAMINATION:

ABDOMEN:

INSPECTION: Shape:distended

Flanks:free

Umbilicus: central &inverted 

no scars,no scratches, 

No dilated veins

Movements are normal

No visible pulsations 

Cullens sign-negative

Gray turners sign-negative

PALPATION:no raise of temperature 

 tenderness in the epigastric region 

Kidney and spleen not palpable 

no  palpable mass

PERCUSSION:Free fluid seen

Shifting dullness seen

AUSCULTATION: bowel sounds heard

No bruit

RESPIRATORY:

INSPECTION: Chest: symmetrical

Trachea:central

No drooping of shoulders,

no supraclavicular hollowing

 no kyphoscoliosis

 no use of accessory respiratory muscles

Blister seen on right shoulder 

Movement with respiration is symmetrical on both sides

PALPATION:trachea: central

no intercoastal widening 

Whole thorax measurement:35inches

Hemi Thorax:17.5inches 

Vocal fremitus -normal 

PERCUSSION:Dullness noted from 5th intercoastal space 

AUSCULTATION: vesicular breath sounds

No added sounds

CVS:

S1&S2 heard

No thrills,no murmurs

CNS:

Concious

Speech:normal

Gait: normal 

No signs of neck stiffness

Sensory system :normal

Motor system: normal 

Provisional diagnosis:

Superficial facial burns 

 acute pancreatitis

 gastritis

INVESTIGATIONS:

TREATMENT:

Inj.Pan 40mg /IV/OD

IVF NS RL 100ml/hr

Inj.Tramadol 1ampule in 100ml NS IV/BD

Tab:augmentin 625mg PO/BD

Tab.chymoral forte PO/TID

FINAL DIAGNOSIS: Superficial facial burns and acute pancreatitis.