24year old female pt with pain abdomen and fever since 5days

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.   

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 diagnosis and treatment plan.

Pt was brought to casualty with c/o fever and Pain abdomen since 26/1/24 and c/o vomitings since 27/1/24.

HISTORY OF PRESENTING ILLNESS:

Pt was apparently asymptomatic 5days back i.e.,(25/1/24) then she developed fever insidious in onset,gradually progressive with no aggravating and relieving factors.

Pain abdomen started initially in epigastrium radiating to back associated with vomitings on 1st day 4episodes non bilious and non projectile.

No h/o cough,cold and breathlessness.

PAST HISTORY:

N/k/c/o DM,HTN,ASTHMA,EPILEPSY,TB, CAD and CVA

PERSONAL HISTORY:

Diet:mixed

Appetite: normal

Sleep: adequate

Bladder movements:regular

Bowel movements:Loose stools since 2days

Addictions:No

FAMILY HISTORY:Not significant

MENSTRUAL HISTORY:

Age of menarche-11yrs

Menstrual cycles-irregular(8days/3-4months,  4-5pads/day, no pain and no clots present)

Marital life-9yrs.

C/o amenorrhea since 2yrs.

Spotting since 4-5days

GENERAL PHYSICAL EXAMINATION:

Pt is c/c/c,

GCS fair(15/15) 

Height:160cm

Weight:102kg

 BMI:39.8kg/m2(overweight)

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

VITALS AT ADMISSION:

Temp:100°F

BP:140/90mmhg

PR:125bpm

RR:20 cpm

GRBS:99mg/dl

Spo2: 94%@RA

SYSTEMIC EXAMINATION:

CVS: S1 S2 heard, no murmurs

CNS:No focal neurological deficit

RS:BAE + NVBS+

P/A: 

Inspection:Obese abdomen with no scars, sinuses present.

Palpation: Soft, obese, tenderness present in epigastric region,umbilical region, right and left hypochondric region and hypogastric region.

Murphy's sign-positive.

Auscultation:Bowel sounds present.

INVESTIGATIONS:

◆Serum amylase:56 IU/L

◆Serum lipase:29 IU/L

◆Hemogram-(30/1/24)   (1/2/24)    (2/2/24)

Hemoglobin -11.5            10.8        11.4

TLC-               18700      15400      15100

Neutrophils-      82          81              81

Lymphocytes-   13         12             14

Eosinophils-.     01         02           01

Monocytes-       04        05         04

Basophils-        00         00        00

PCV-.              33.8      32.4     33.9

MCV:           72.7       73.1        72.7

MCH:          24.7        24.4      24.5

MCHC:        34.0       33.1      33.8

RDW-CV:     16.1      15.8     15.5

SMEAR: Normocytic normochromic with neutrophilic leuckocytosis.

◆SEROLOGY-NEGATIVE.

◆UPT-Negative.

◆RBS-107mg/dl

◆FBS-79mg/dl

◆HBA1C-6.4

                   (30/1/24)     (1/2/24)

◆Blood urea-21mg/dl      15mg/dl

◆Serum creatinine-0.8     0.8mg/dl

◆CUE:

Colour- pale yellow

Albumin- +

Sugars,bile salts and bile pigments-nil

Pus cells-3-4

Epithelial cells:2-3

◆LFT: (30/1/24) (1/2/24)

TB-        1.42      1.14

DB-        0.33     0.16

AST-        16      21

ALT-        25        21

ALP-     198         190

TP-           6.6       6.4

ALBUMIN-.  3.2    3.3

A/G RATIO-1.00     1.05

◆Thyroid profile:

T3-0.75

T4-15.13

TSH-3.08

◆Lipid profile:

Total cholesterol-156

Triglycerides-117

HDL-117

LDL-82

VLDL-23

◆Serum electrolytes:

  (30/1/24)     (1/2/24)

Na-136       139

K-    3.6         3.6

Cl-      99        103

Ca++:  1.14   1.25

◆USG ABDOMEN AND PELVIS(31/1/24)

IMPRESSION:

●Cholelithiasis

●Acute pancreatitis

●Grade I fatty liver with hepatomegaly

●Borderline splenomegaly.

◆CT abdomen:

Impression-

●Acute edematous interstitial pancreatitis with no necrosis.

●No vascular complications

●No fluid collections

●Modified CT severity index 4/10

●Screening of USG Abdomen showed cholelithiasis

◆-ECG

PROVISIONAL DIAGNOSIS:

Acute pancreatitis secondary to gallbladder calculus with morbid obesity with secondary amenorrhea.

TREATMENT:

IV FLUIDS NS,RL,DNS @100ml/hr

INJ.PAN 40mg IV/OD

INJ.ZOFER 4mg IV/SOS

INJ.TRAMADOL 1amp in 100ml IV/BD

INJ.OPTINEURON 1amp in 100ml NS@100ml/hr IV/OD

INJ.MONOCEF 1gm IV/BD

TAB.SPOROLAC-DS PO/TID

TAB.RODETIC 100mg PO/BD