A 40 years male with hematemesis

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent.

 Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

CASE SCENARIO : 

A 40 year male, came to casualty with complaints of 10 episodes of blood vomiting  since yesterday afternoon

History of presenting illness :

Patient was asymptomatic since yesterday afternoon and then developed blood vomiting which is sudden in onset, non projectile, and no aggrevating and relieving factors

Patient is known case of peptic ulcer

No history of fever, constipation, loose stools , burning micturition

History of past illness :

History of similar complaints in the past 6 months ago and admitted in GM Kims, Narkepally.

Not a known case of DM , HTN, epilepsy, asthma CAD and CKD 


O/E : 

pt is c/c/c,

Pallor - absent

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - absent

Pedal edema - b/l present

Vitals:

Afebrile

Bp: 120/80 mm hg

PR: 80 bpm

RR: 20 cpm

SpO2: 99% @RA litres of oxygen

GRBS : 120 mg %

Systemic examination : 

— CVS 

- Thrills : No 

- Cardiac sounds - S1 , S2 heard 

- Cardiac murmurs : No 

— RS 

- Dyspnea : No 

- Wheeze : No 

- Position of Trachea : central 

- Breath sounds :  Vescicular

— ABDOMEN 

- Shape of abdomen : Scaphoid

- No tenderness , palpable mass 

- Hernial orrifices : Normal 

- No fluids , bruits 

- Liver and Spleen are not palpable

- Bowel sounds :  Yes 

CNS -
Speech : Normal
Level of conscious : Alert
No neck stiffness
Cranial system : NAD
Motor system : NAD
Sensory system : NAD
Glassgow scale : 15/15

Reflexes-
                    Biceps   Triceps   Supinator  Knees  A
RL:.              +            +               +                +         +
LL:.               +            +              +                 +         +

    Tone:  Rt .UL :Normal
             Lf. UL: Normal
             Rt. LL : Normal
             Lf. LL: Normal

Power: Rt .UL: Normal
             Lf. UL: Normal
             Rt. LL: Normal
             Lf. LL: Normal

Cerebral signs :
Finger nose in-coordination : no
Knee heal in-coordination : no

Gait : NAD

INVESTIGATIONS :

 09/08/2022











 11/08/2022


           





 
Diagnosis :
            
        OESOPHAGEAL VARICES




09/08/2022

On examination :

Patient is C/C/C

BP : 110/80 mm of Hg

PR : 76/min

CVS : S1, S2 present

RS : BAE +

P/A soft and tender

NBM till further orders

IVF : RL}.   100 ml/hr
         NS} 

Inj .Pan IV

Inj. Tranexa IV / BD

Inj . Zofer IV / BD

MONITER VITALS 

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