67F PTB ACUTE CALCULOUS CHOLECYSTITIS
66 YEAR OLD FEMALE CAME WITH
-C/O ABDOMINAL DISTENTION SINCE TODAY MORNING(8/6/23).
-C/O BURNING TYPE OF PAIN IN UPPER ABDOMEN SINCE 2 DAYS.
HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC 2 DAYS BACK AND THEN DEVELOPED BURNING TYPE OF PAIN IN UPPER ABDOMEN. NO AGGRAVATING AND RELIEVING FACTORS, PAIN NOT RADIATING TO ANY OTHER QUARDRANT.
NO H/O FEVER, CONSTIPATION, VOMITING, BURNING MICTURITION.
NO H/O TRAUMA.
H/O DECREASED APPETITE SINCE 20 DAYS(SINCE USAGE OF ATT).
PAST HISTORY:
H/O HYSTERECTOMY DONE IN 2001.
N/K/C/O DM, HTN, CVA, CAD, EPILEPSY.
H/O ASTHMA SINCE 35 YEARS.
H/O TB, DIAGNOSED LAST MONTH AND STARTED ATT.
PATIENT HAD C/O PAIN IN RUA 20 DAYS BACK AND GOT ADMITTED UNDER GS-VI AND USG WAS DONE SHOWING CHOLELITHIASIS.
HRCT CHEST- MULTIPLE CENTILOBULAR NODULES IN BOTH LUNGS.
ON EXAMINATION:
PALLOR(+)
NO SIGNS OF CLUBBING, CYANOSIS, ICTERUS, EDEMA TEMP-AFEBRILE, BP-120/80 MMHG, PR-86BPM, RR-32CPM,SPO2-99% @2L 02,GRBS-136MG%
PER ABDOMEN INSPECTION: -ABDOMEN IS DISTENDED
-UMBLICUS IS CENTRAL AND INVERTED.
-NO SINUS, HYSTERECTOMY SCAR (+)
-NO ENGORGED VEINS.
-ALL QUADRANTS OF ABDOMEN MOVES EQUALLY WITH RESPIRATION
-NO VISIBLE GASTRIC PARALYSIS.
PALPATION:-SOFT, NON-TENDER, NO GUARDING, NO RIGIDITY AUSCULTATION-BOWEL SOUNDS -PRESENT
RESPIRATORY SYSTEM:
TRACHEA CENTRAL, BAE+, NVBS HEARD RHONCHI PRESENT
Investigation
2D ECHO(8/6/23):
TRIVIAL TR(+/AR(+), NO MR
NO RWMA, NO AS/MS, SCLEROTIC AV.
GOOD LV SYSTOLIC FUNCTIONS.
DIASTOLIC DYSFUNCTION(+), NO PAH/PE.
USG-ABDOMEN(8/6/23):
-E/O MULTIPLE CALCULI NOTED IN GALL BLADDER IN FUNDUS AND NECK, LARGEST MEASURING 8MM.
-NO PERICHOLECYSTIC COLLECTION.
-NO GB WALL EDEMA.
USG-CHEST(9/6/23):
-ACUTE CALCULOUS CHOLECYSTITIS WITH COLLECTION AND SEALED OFF PERFORATION.
-NO SONOLOGICAL ABNORMALITIES IN THE CHEST.
Treatment Given(Enter only Generic Name)
02 INHALATION WITH 1-LITRE 02 WITH NASAL PRONGS TO MAINTAIN SPO2>94% SOFT DIET
INJ. MEROPENUM 1GM SLOW IV/TID INJ.METROGYL 500MG IV/BD
INJ.AMIKACIN 500MG IV/BD
TAB. ZOFER 4MG PO/SOS TAB. ACELO PO/BD TAB. CHYMEROL FORTE PO/TID ATT(4 TABS) PO/OD TAB. BENEDON 40MG PO/OD INJ. PAN 40MG IV/BD INJ.BUSCOPAN IM/STAT IVF NS 500ML ,75ML/HR ,IV/BD
INJ. PIPTAZ 4.5GM IV/TID
NEB. WITH IPRAVENT X 8TH HOURLY NEB. WITH BUDECORT X 12TH HOURLY.
PROTEIN POWDER 2 TS WITH 1GLASS OF MILK (TID)
CHEST PHYSIOTHERAPY INTENSIVE SPIROMETRY 2ND + JURLY
Advice at Discharge
TAB. TAXIM-O 200MG PO BD (X-1-1) TAB. PANTOP 40MG PO OD (BBF) X5 DAYS TAB. BUSCOPAN 10 MG PO SOS TAB. MVT PO OD X 5 DAYS CST
CONTINUE ATT UNDER NTEP 4 TABS PER DAY
INS. PIP TAL 4.5GM IV/TID
NEB. WITH IPRAVENT X 8TH HOURLY NEB. WITH BUDECORT X 12TH HOURLY.
PROTEIN POWDER 2 TS WITH 1GLASS OF MILK (TID)
CHEST PHYSIOTHERAPY INTENSIVE SPIROMETRY 2ND + JURLY
Advice at Discharge
TAB. TAXIM-O 200MG PO BD (X-1-1) TAB. PANTOP 40MG PO OD (BBF) X5 DAYS TAB. BUSCOPAN 10 MG PO SOS TAB. MVT PO OD X 5 DAYS CST
CONTINUE ATT UNDER NTEP 4 TABS PER DAY
TAB. BENADON 40 MG PO/OD
INHALER FORGLYN MDI WITH SPACER (BEFORE BREAKFAST 2 WEEKS)
HIGH PROTEIN DIET 2 EGG WHITES PER DAY
OUTCOME COMPLETELY RECOVERED
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