A 45 YEAR OLD MALE WITH PAIN IN THE ABDOMEN

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 VIJAYA RATNA 34


A 45 year old female farmer by occupation resident of nalgonda came to casualty with chief complaints of 

        Epigastric pain since 2 days

        Shortness of Breath since 1 day [ Grade I to Grade II]

        Cough with expectoration since 1 day

HISTORY OF PRESENT ILLNESS

        The patient was apparently asymptomatic till today evening.Then she developed  sudden episode of shortness of breath,progressive from grade I to grade II with wheeze.No diurnal and postural variation.Burps present.

She even had H/o epigastric pain since 2 days.

c/o cough with expectoration since 1 day,sudden in onset,mucoid, on and off ,no foul smelling,no hemoptysis.

No c/o of fever or chest pain , chest tightness , decreased urine output , palpitations, sweating.

HISTORY OF PAST ILLNESS

Not a known case of Hypertension,DM,CAD,Epilepsy,TB

No loss of weight,No loss of appetite

PERSONAL HISTORY

Appetite - Normal

Mixed Diet

Bowels - Regular

Micturition - Normal

No Allergies

No other addictions

FAMILY HISTORY

No family History

GENERAL EXAMINATION

        Patient was conscious,coherent,cooperative and examined in a well lit room

VITALS

Temperature - 98.6F

Pulse rate - 86/min

Respiratory rate - 24 cpm

BP - 120/80 mmHg

SpO2 - 93% at room air

GRBS - 156 mg%


PHYSICAL EXAMINATION

Pallor - absent

Icterus - absent

Cyanosis - absent

Clubbing of fingers/toes - absent

Lymphadenopathy - absent

Malnutrition -  absent

dehydration – absent


SYSTEMIC EXAMINATION

CVS :S1,S2 heard,no murmurs heard

Resp:BAE +

Abdomen:Scaphoid in shape

Tenderness present,no palpable mass

Bowel sounds present

CNS:NAD


INVESTIGATIONS

ECG


2D ECHO


HBsAg - RAPID

ANTI HCV ANTIBODIES - RAPID

COMPLETE BLOOD PICTURE

Haemoglobin - 14.1gm/dl

Total Leucocyte count - 21900 cells/cu.mm

Platelet Count - 1.91 lakhs/cu.mm

IMPRESSION : Neutrophilic Leucocytosis

4/3


PROVISIONAL DIAGNOSIS

Bronchial Asthma


TREATMENT

O2 inhalation nasal prongs 2-4lts/min

Inj Hydrocort 100mg/iv/TID

Neb Ipravent, Budecort

Inj Tan 40mg/iv/BD

T.mucinac 600 - 1 tablet in glass of water TID

Chest physiotherapy

T.Montac 

Inj Ceftriaxone 1gm/iv/BD

Monitor vitals




        

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