A 55 year old male patient farmer by occupation came to the opd with the chief complaints of oil spillage and pain in the abdomen

Welcome and greetings to every one who are visiting my blog. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan. 

A 55 year old male patient farmer by occupation came to the opd with the chief complaints of oil spillage and pain in the abdomen two days back

HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic  3years back ,then he had fever  associated with body aches for which he went to a hospital where he was diagnosed with diabetes mellitus and was on oral hypoglycemics since then .2days back,he underwent trauma (thermal burns -oil spillage as he had stepped on fire camp)under the effect of alcohol (90ml that morning) which caused  superficial burns over the face  and blisters over the right shoulder
pain in epigastric region which is squeezing in nature,non radiating,not associated with nausea,vomiting.


HISTORY OF PAST ILLNESS:

Patient is a known case of diabetes (since 3years for which he is on vildagliptin and metformin medication)
Not a known case of hypertension, asthama, epilepsy, tuberculosis,CAD 
No history of previous surgery 

PERSONAL HISTORY:
Married,2girl children and a male child
Appetite:normal
Diet: mixed
Sleep: adequate
Bowel and bladder: normal
Addictions: alcoholic(90ml per day) since 30years,smoking (3-4cigars per day)
No significant drug history

GENERAL EXAMINATION:
Patient was concious coherent cooperative and well oriented to time place and person
No pallor, cyanosis, clubbing, icterus, bilateral pedal edema, generalized lymphadenopathy 


VITALS:
Temperature: afebrile 
Pulse rate:78bpm
Bp:140/80 mm/hg
Respiratory rate:16 cpm
SpO2:98

SYSTEMIC EXAMINATION:
ABDOMEN:
INSPECTION: Shape:scaphoid
Flanks:free
Umbilicus: central &inverted 
no scars,no scratches, normal hernial orrifices
 
PALPATION: tenderness in the epigastric region 
Kidney and spleen not palpable ,no other palpable masse

AUSCULTATION: bowel sounds:3-4

RESPIRATORY:
INSPECTION:Cheat: symmetrical
Trachea:central
No drooping of shoulders,no supraclavicular hollowing ,no kyphoscoliosis
Blisters over right shoulder, no use of accessory respiratory muscles
PALPATION:trachea: central,no intercoastal widening 
Whole thorax measurement:35inches
Hemi Thorax:17.5inches 

AUSCULTATION: vesicular breath sounds
No added sounds

CVS:
S1&S2 heard
No thrills,no murmurs

CNS:
Concious
Speech:normal
Gait: normal 
Sensory system :normal
Motor system: normal 

Provisional diagnosis:
Superficial facial burns and acute pancreatitis

Investigations 

TREATMENT:
Inj.Pan 40mg /IV/OD
IVF NS RL 100ml/hr
Inj.Tramadol 1ampule in 100ml NS IV/BD
Tab:augmentin 625mg PO/BD
Tab.chymerol forte PO/TID

FINAL DIAGNOSIS: Superficial facial burns and acute pancreatitis.

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