SHORT CASE

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January 18, 2023

A 55 year old male patient  shepherd by occupation came with chief complaint of burns over the face due to spillage of oil and pain in abdomen since last 4 days

Date of admission : 14 / 01 /2023

HISTORY OF PRESENT ILLNESSES

Patient was apparently asymptomatic  3 years back ,then he had fever associated with body aches for which he went to a hospital where he was diagnosed with diabetes mellitus and he was on oral hypoglycemics . Then 2 days back,he underwent trauma with  burns due to oil spillage as he had stepped on fire camp under the effect of alcohol  which caused  superficial burns over the anterior part of 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 on a oral antidiabetic medication since 3 years

-Drugs used are  vildagliptin and metformin 

-No h/o  hypertension, asthama, epilepsy, TB

-No history of any previous surgery 

FAMILY HISTORY:

Not significant 

PERSONAL HISTORY:

-Diet: mixed 

-Appetite : Normal

-Sleep: adequate

-Bowel and bladder: regular

-Addictions: he is an alcoholic and takes about 90ml per day since 30years and  he smokes about 3-4 cigarettes per day

Drug history:

no known history of any drug allergy 

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 

Built : moderate

VITALS:

Temperature: afebrile 

Pulse rate:78bpm

Respiratory rate:16 cpm

BP : 140/80 mmHg

SpO2 : 98%

SYSTEMIC EXAMINATION:

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 local rise of temperature 

 -tenderness in the epigastric region 

-Kidney and spleen not palpable 

-No palpable mass

PERCUSSION:

-Free fluid seen

-Shifting dullness seen

AUSCULTATION:

 -bowel sounds heard

-No bruit

RESPIRATORY SYSTEM:

INSPECTION:

 -Chest: symmetrical

- No scars ,scratches

-Trachea:central

-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 from 5th intercoastal space 

AUSCULTATION: 

-vesicular breath sounds

-No added sounds

CVS:

-S1&S2 heard

-No thrills,no murmurs

CNS:

-Consciousness

-Speech : normal

-Gait : normal 

-No signs of neck stiffness 

-kerning sign - negative

PROVISIONAL DIAGNOSIS:

Superficial facial burns 

 acute pancreatitis

 gastritis 

INVESTIGATIONS

CLINICAL IMAGES 

FINAL DIAGNOSIS:

 Superficial facial burns and acute pancreatitis.

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.chymoral forte PO/TID