A case of 55 year old male

 Name: J. Akash

 17/01/2023

Roll no. 53

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 :

55year old male, who is shepherd by occupation was apparently asymptomatic 3 years back , then had fever with Generalized body pains for which he went to the hospital, diagnosed with Diabetes and was on OHAs since 3 years .He used to take alcohol 90ml in the morning and 90 ml in the evening, and 5-6 beedis per day and on Saturday, patient had intake of 90ml of alcohol in the morning and came to home , his daughter was preparing the sweet at 1pm and he came to his daughter to take his phone , for calling his son, had step on the fire camp ( where food was preparing)and suddenly oil ( which is being used for cooking ) fell on his face and had burns on the anterior part of his entire face, admitted under surgery department and after admission patient had pain abdomen, where serum amylase and lipase was elevated and case was taken over by medicine department.

Patient came with A/H/O trauma H/o oil  spillage over face on 14/1/23 around 1:30pm under influence of alcohol and sustained superficial burns over face and Right shoulder

No H/o Loc , seizures,head injury

No h/o fever, nausea, vomitings

No h/o chest pain,sob, palpitations

No h/o burning micturition,loose stools

O/E

Pt conscious coherent co-operative

afebrile

BP-140/80mmhg

PR-78bpm

Spo2-98%

CVS- S1 S2 heard

RS- BAE clear, NVBS

P/A - Soft, No distension,no rigidity

Pupils:B/L NSRL

GCS- E4 V5 M6

CCT PCT- negative

No spine and long bone tenderness

No gait abnormality

Past history: 

K/C/O DM since 3years and on glimi M1

Not a K/C/O ,HTN,TB,ASTHMA, EPILEPSY,CAD

Regular alcoholic & smoker since 25 years

INSIGNIFICANT FAMILY HISTORY

GENERAL EXAMINATION:

Pt conscious coherent co-operative

No signs of pallor clubbing cyanosis Icterus lymphadenopathy edema

LOCAL EXAMINATION:

Facial edema +

Blackish discoloration over Rt ear,face

blebs over Rt shoulder

3-5% burns grade 1-2 over face,Rt shoulder secondery to chemical burns

Fine , crude touch sensations present 

Pain over facial region

Tenderness over lips

INVESTIGATIONS:   16/1/23    17/1/23   18/123

Serum amylase:     703 IU/L    255 IU/L   105 IU/L

serum lipase:        244  IU/L      85 IU/L      42 IU/L

CHEST XRAY PA view

15/1/23

17/1/2023

ECG:

2D echo

USG ABDOMEN:

CECT ABDOMEN

PROVISIONAL DIAGNOSIS:

Superficial burns 3-5% secondery to A/H/O trauma due to chemical burns

Acute pancreatitis K/C/O DM type 2 since 3years

TREATMENT GIVEN:

15/1/2023

Tab.Augmentin 625mg po/BD

Tab.pan 40 po/od

Tab.ultracet po/bd

glatifloxacin eyedrops

Tab Chymerol forte po/TID

Oint. Silver X L/A

Tab. Glimi M1 po/BD

16/01/2023

UNIT 5 

DR HIMAJA, PGY1

DR PAVANI, PGY2

DR SAICHARAN, PGY3

DR ABHINAYA, SR

DR AKASH, INTERN

DR HYNDAVI, INTERN

 ICU DAY 1

 Age:55 Gender:M

S:

Stools not passed

Abdominal pain subsided

No fever spikes

O:

Pt conscious coherent co-operative

afebrile

BP-130/90mmhg

PR-78bpm

RR-20cpm

Spo2-98%

CVS- S1 S2 heard

RS- BAE clear, NVBS

P/A - Soft, No distension,no rigidity

CNS- No focal deficit

A:

Superficial burns 3-5% secondery to A/H/O trauma due to chemical burns

Acute pancreatitis K/C/O DM type 2 since 3years

3-5% grade 1-2 Facial burns

P:

IVF NS RL @100ml/hr

Inj.Tramadol 1amp in 100ml NS

D2 Tab.Augmentin 625mg po/BD

Tab.pan 40 po/od

glatifloxacin eyedrops

Tab Chymerol forte po/TID

17/01/2023

UNIT 5 

DR HIMAJA, PGY1

DR PAVANI, PGY2

DR SAICHARAN, PGY3

DR ABHINAYA, SR

DR AKASH, INTERN

DR HYNDAVI, INTERN

 AMC DAY 2

 Age:55 Gender:M

S:

Stools not passed

Abdominal pain subsided

No fever spikes

O:

Pt conscious coherent co-operative

afebrile

BP-120/80mmhg

PR-127bpm

RR-18cpm

Spo2-98%

CVS- S1 S2 heard

RS- BAE clear, NVBS

P/A - Soft, No distension,no rigidity

CNS- No focal deficit

A:

Superficial burns 3-5% secondery to A/H/O trauma due to chemical burns

Acute pancreatitis K/C/O DM type 2 since 3years

3-5% grade 1-2 Facial burns

P:

IVF NS RL @100ml/hr

Inj. Piptaz 4.5g IV/TID

Inj.Tramadol 1amp in 100ml NS

D3 Tab.Augmentin 625mg po/BD

Tab.pan 40 po/od

Lubex eyedrops QID

Tab Chymerol forte po/TID

Oint. Silver nitrite lignocaine L/A

Syp . Cremaffin 20ml Po/BD