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