A 55 YEAR OLD MALE PATIENT WITH SUPERFICIAL BURNS AND ACUTE PANCREATITIS

January 18,2023

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 shepherd by occupation  came to the opd with the chief complaints of burns over the face due to oil spillage and pain in the abdomen since two days .

Date of admission:14/01/2023

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic  3years back ,then he noticed fever associated with body aches for which he went to a hospital where he was diagnosed with diabetes mellitus and was on oral hypoglycemic agents since 3years. Then 3 days back, he underwent trauma ( 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 oral hypoglycemic drugs (vildagliptin and metformin )

Not a known case of  hypertension, Asthma, epilepsy, tuberculosis,CAD 

No history of previous surgery 

FAMILY HISTORY: 

No significant family history .

PERSONAL HISTORY:

Diet: mixed

Appetite:normal

Sleep:adequate

Bowel and bladder movements: normal

Habits:-Patient has habit of consuming alcohol(90ml in the morning& 90ml in the evening) every day since 30years and smoking (5-6 beedis per day)

DRUG HISTORY:

 Not a known case of allergic to known drugs. 

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:

Built : moderate

Temperature: afebrile 

Pulse rate:78bpm

Bp:120/80 mm hg

Respiratory rate:16 cpm

SpO2:98%

SYSTEMIC EXAMINATION:

A)ABDOMEN:

Inspection:

Shape:distended

Flanks:free

Umbilicus: central &inverted 

No scars

No scratches

No dilated veins

Movements are normal

No visible pulsations 

Cullens sign-negative

Gray turners sign-negative

Palpation:

No raise in temperature .

Tenderness in the epigastric region .

Kidney and spleen are not palpable .

No  palpable mass.

Percussion:

Free fluid present

Shifting dullness seen

Auscultation:

Bowel sounds heard

No bruit

B) RESPIRATORY

Inspection:

Chest: symmetrical in shape 

Trachea:central in position 

No drooping of shoulders

No supraclavicular hollowing

No kyphoscoliosis

No use of accessory respiratory muscles

Blister seen on right shoulder 

Movement with respiration is symmetrical on both sides

Palpation:

Trachea: central

No intercoastal widening 

Whole thorax measurement:35inches

Hemi Thorax:17.5inches 

Vocal fremitus -normal 

Percussion:

Dullness noted at 5th intercoastal space 

Auscultation:

Vesicular breath sounds

No added sounds

C) CVS:

S1&S2 heard

No thrills,no murmurs

D) CNS:

Concious

Speech:normal

No signs of neck stiffness

Sensory system :normal

Motor system: normal 

PROVISIONAL DIAGNOSIS:

Superficial facial burns 

Acute pancreatitis

Gastritis




INVESTIGATIONS:

USG Abdomen

Chest x-ray

ECG


FINAL DIAGNOSIS: 

Superficial facial burns and acute pancreatitis.


TREATMENT:

Inj.Pan 40mg /IV/OD

IV NS RL 100ml/hr

Inj.Tramadol 1ampule in 100ml NS IV/BD

Tab.Augmentin 625mg PO/BD

Tab.Chymoral forte PO/TID















 















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