30YEAR OLD MALE WITH EPIGASTRIC PAIN
30 year male with epigastric pain
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Complaints-
c/o pain over epigastric region since 8:45pm yesterday.
HOPI-
Pt was apparently asymptomatic 1 months back then developed pain over epigastric region, aggravated with spicy food intake and relieved on medication.
Had similar complaints 3 days ago, relieved with medication.
Now patient presented with pain over epigastric region since 8:45 pm, localised over the region, non radiating, tenderness present.
No SOB, palpitations, orthopnea, PND.
No c/o fever, vomitings, diarrhea.
Past history:
Not a k/c/o HTN, DM, thyroid disorders,epilepsy, CVA, asthma.
General examination-
Patient is C/C/C
BP-130/80mmhg
PR- 96 bpm
RR- 18cpm
GRBS- 104 mg/dl
Temp- 98.2F
SYSTEMIC EXAMINATION
CVS- S1S2+,NO MURMURS
RS- BAE+,NVBS HEARD
P/A- SOFT,NON TENDER,BOWEL SOUNDS+
CNS- ORIENTED TO TIME,PLACE AND PERSON
Diagnosis- acute cholecystitis with cholelithiasis
Treatment-
- Normal diet allowed
- Plenty of oral fluids
- Inj. Pan 40mg PO BD
- Inj. Tramadol 1amp in 100ml NS IV/ SOS
- Inj. Thiamine 200mg PO/TID
- Tab. TAXIM 200 mg PO/BD
- TAB. METROGYL 400mg PO/TID
- Monitor vitals 4th hourly
- Inform SOS
CLINICAL IMAGES
Investigations
SUMMARY
Diagnosis- acute cholecystitis with cholelithiasis
Complaints-
c/o pain over epigastric region since 8:45pm yesterday.
HOPI-
Pt was apparently asymptomatic 1 months back then developed pain over epigastric region, aggravated with spicy food intake and relieved on medication.
Had similar complaints 3 days ago, relieved with medication.
Now patient presented with pain over epigastric region since 8:45 pm, localised over the region, non radiating, tenderness present.
No SOB, palpitations, orthopnea, PND.
No c/o fever, vomitings, diarrhea.
Past history:
Not a k/c/o HTN, DM, thyroid disorders,epilepsy, CVA, asthma.
General examination-
Patient is C/C/C
BP-130/80mmhg
PR- 96 bpm
RR- 18cpm
GRBS- 104 mg/dl
Temp- 98.2F
SYSTEMIC EXAMINATION
CVS- S1S2+,NO MURMURS
RS- BAE+,NVBS HEARD
P/A- SOFT,NON TENDER,BOWEL SOUNDS+
CNS- ORIENTED TO TIME,PLACE AND PERSON
Treatment-
- Normal diet allowed
- Plenty of oral fluids
- Inj. Pan 40mg PO BD
- Inj. Tramadol 1amp in 100ml NS IV/ SOS
- Inj. Thiamine 200mg PO/TID
- Tab. TAXIM 200 mg PO/BD
- TAB. METROGYL 400mg PO/TID
- Monitor vitals 4th hourly
- Inform SOS
ADVICE AT DISCHARGE
Plenty of oral fluids
Tab Pan 40mg po/od/bbf
Tab thiamine 200mg po/bd
Tab taxim 200mg po/bd for 4 days
Tab metrogyl 400mg po/tid for 4 days
Review to surgery and medicine OPD after 1 week
