AMC case unit 5

 

A 65 yr old male came to casuality with

CHEIF COMPLAINTS

  Diffuse chest pain and right sided abdominal  pain since yesterday morning 3am 

 vomitings since yesterday evening 

HISTORY OF PRESENT ILLNESS:

 pt was apparently asymptomatic 4day ago then he had on and off right sided  abdominal pain gradually progressive radiating to back not relieving on rest and pt also had 2 episodes  of vomiting non bilious , non projectile , food as content . 

Associated with chest pain which was insidious in onset gradually progressive 

Squeezing type of pain .

PAST HISTORY 


He had similar complaints  1 year ago , treated conservatively .


NO HTN,DM,ASTHMA,epilepsy,CAD

PERSONAL HISTORY 

Pt was chronic alcoholic from 10years ,daily he consumes 90ml/day 

Last intake of alcohol - 1 day ago 

No H/0 of loose stools , fever , palpitations ,constipation ,burning micturition 


O/E: Patient is conscious ,coherent and cooperative moderately built and moderately nourished 

No pallor/Icterus/Cyanosis/Clubbing/Generalised Lymphadenopathy/Pedal edema


Temp:Afebrile

PR:88 bpm

BP:140/90mm of hg

CVS:S1,S2 heard,no murmurs

RS:BAE ,NVBS heard

P/A:SOFT,Bs , Tenderness present in right hypochondrium and right lumbar region 

Murphy’s sign



























4/3/2022  9:00AM

4/3/2022 10:16AM


4/3/2022  12:45PM


6/3/2022  7:10AM




Usg abdomen : cholelithiasis 2 calculi 12 mm each . 

Gb wall thickened measuring 9mm

No evidence of any pericholecystic collection .

Diagnosis : CHOLELITHIASIS WITH ACUTE CHOLECYSTITIS .

Treatment : 

  1. NBM Till further orders 
  2. IVF 1 NS , RL , DNS @ 75ml /hr 
  3. Inj . TAXIM 1gm IV/bd 
  4. Inj.Metrogyl  400mg IV tid 
  5. Inj pan 40 mg IV od 
  6. Inj tramodol in 100 ml ns 
  7. Inj . Zofer 4 mg IV /od 
  8. PR/Bp monitoring hourly 


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