16/M WITH C/O ABDOMINAL PAIN AND VOMITINGS.


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Here is a case I have seen

Unit 6:

Case admitted in ICU on 30/1/2021.

Interns 

K. Nikhil reddy

M. Swarna 

K. Divya

 B.Manivarma

Juveria 


 Dr. Vinay(pgy1)

Dr. Rashmitha(pgy2)

Dr. A. Vaishnavi (pgy2) 

Dr.  Sai Radha(pgy3)

Dr. Hareen (SR)

Dr.Praveen Naik( asst.prpff)

Dr.Rakeah Biswas (HOD)

Here is the case we have seen.

A 16 year old male student,  resident of Ramannapet, came to casuality with Chief complaints of abdominal pain since 4 days,

 vomitings since 3 days.

H/o present illness:

Patient was apparently asymptomatic 25 days back, later he had C/o vomitings 25 days back,2 episodes followed by severe sweating ,for which he went to local hospital and relieved on medication.

15 days back, he had 2 episodes of fever spikes, high grade, associated with headache ,not associated with vomiting, relieved on medication.

5 days back , he complaints of fever, low grade, associated with chills, on and off,subsided with medication.

Now,  he complaints of severe pain in epigastric region, mild pain in right and left hypochondriall region  since 4 days, aggrevated on lying in lateral position, no relieving factors and vomitings since 3 days ,3 episodes,associated with food particles, non bilious , not associated with blood.

No complaints of cold, cough.

No complaints of chest pain, palpitations, syncopal attacks, shortness of breath, orthopnea,PND.

 No complaints of burning micturition, constipation, diarrhoea.

No known allergies

No significant family history.

  O/E:

Patient is conscious, coherent,cooperative.

Icterus +

No pallor, cyanosis, clubbing , lymphadenopathy,pedal edema.

Temp: afebrile

Bp:140/70 mmhg

PR: 68 bpm

RR:22cpm

GRBS:121mg/dl.

Spo2:98% at room air


 Systematic examination:

P/A: soft, tenderness noted in epigastric and left and right hypochondrium.

RS: BAE +,NVBS +

CVS: S1,S2 heard ,no murmurs 

CNS: HMF +, No abnormality  detected.

Clinical images:




Investigations:
       HEMOGRAM
     CUE
LFT

RFT

SEROLOGY

FEVER CHARTING
ECG
CHEST X RAY


USG-ABDOMEN on 30/12/2021

USG ABDOMEN on 1/2/2021
2D.ECHO

 
Diagnosis:
ACUTE CHOLECYSTITIS WITH ?CHOLANGITIS WITH DENOVO DIAGNOSED HBsAg+

TREATMENT GIVEN:
1.Inj.ZOFER 4mg IV /OD
2.Inj. PAN 40mg IV/OD
 3. Tab.METROGYL 400md po/TID
4. Tab.CIFRAN 500mg po/BD
5. Tab.PCM 500mg po/sos
6.Temperature charting
7.tepid sponging sos

31/1/2021

S: vomitings- subsided
     Abdominal pain -not subsided
     No fresh complaints
O:patient is conscious, coherent, cooperative.
    Bp:140/70mmhg
    PR:78 bpm
    RR: 20cpm
     Temp:97 degrees Fahrenheit
    P/A: soft, tenderness in epigastric region and             right and left hypochondrium
    RS: bae+,NVBS+
   CVS: S1,S2 heard. 
A: ACUTE CHOLECYSTITIS WITH ?CHOLANGITIS WITH DENOVO DIAGNOSED HBsAg+
P:
1.Inj. METROGYL 100ML(500MG) IV TID
2.Inj.ZOFER 4mg IV /OD
3.Inj. PAN 40mg IV/OD
4.Inj. CEFTRIAXONE 1 GM IV/BD
5. Tab.PCM 650mg po/sos
6.Inj.TRAMADOL 50 mg in 100ml NS Iv/sos
7. Temperature charting

1/2/2021.

S : vomitings- subsided
     Abdominal pain -not subsided
     No fresh complaints
O:patient is conscious, coherent, cooperative
    Bp:130/70mmhg
    PR : 84bpm
    RR: 20cpm
     Temp:98 degrees Fahrenheit
    P/A: soft, tenderness in epigastric region and             right and left hypochondrium
    RS: bae+,NVBS+
   CVS: S1,S2 heard.
A: ACUTE CHOLECYSTITIS WITH ?CHOLANGITIS WITH DENOVO DIAGNOSED HBsAg+
P:
1.Inj. METROGYL 100ML(500MG) IV TID
2.Inj.ZOFER 4mg IV /OD
3.Inj. PAN 40mg IV/OD
4.Inj. CEFTRIAXONE 1 GM  /IV /BD
5. Tab.PCM 650mg po/sos
6.Inj.TRAMADOL 50 mg in 100ml NS Iv/sos
7. Temperature charting

2/2/2021.
S: vomitings- subsided
     Abdominal pain -not subsided
     No fresh complaints
O:patient is conscious, coherent, cooperative
    Bp:150/110mmhg
    PR : 96bpm
    RR: 26cpm
     Temp:98 degrees Fahrenheit
    P/A: soft, tenderness in epigastric region and             right and left hypochondrium
    RS: BAE+,NVBS+
   CVS: S1,S2 heard.
A: ACUTE CHOLECYSTITIS WITH ?CHOLANGITIS WITH DENOVO DIAGNOSED HBsAg+
P:
1.Inj. METROGYL 100ML(500MG) IV TID
2.Inj.ZOFER 4mg IV /OD
3.Inj. PAN 40mg IV/OD
4.Inj. CEFTRIAXONE 1 GM  /IV /BD
5. Tab.PCM 650mg po/sos
6.Inj.TRAMADOL 50 mg in 100ml NS Iv/sos
7. Temperature charting

3/2/2021.
S: vomitings- subsided
     Abdominal pain -not subsided
     No fresh complaints
O:patient is conscious, coherent, cooperative
    Bp:110/70mmhg
    PR : 74bpm
    RR: 24cpm
     Temp:98 degrees Fahrenheit
    P/A: soft, tenderness in epigastric region and             right and left hypochondrium
    RS: BAE+,NVBS+
   CVS: S1,S2 heard.
A: ACUTE CHOLECYSTITIS WITH ?CHOLANGITIS WITH DENOVO DIAGNOSED HBsAg+
P:
1.Inj. METROGYL 100ML(500MG) IV TID
2.Inj.ZOFER 4mg IV /OD
3.Inj. PAN 40mg IV/OD
4.Inj. CEFTRIAXONE 1 GM  /IV /BD
5. Temperature charting

Patient referred to higher centre for MRCP and further evaluation.

      
 

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