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
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
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