55 Yr old male with c/o burns over the face
A 55 year old male patient who is shepherd by occupation came to the hospital with the chief complaints of burns over the face due to oil spillage and pain in the abdomen since three days.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 3years back ,then he had fever associated with body aches for which he went to a hospital where he was diagnosed with diabetes mellitus and was on oral hypoglycemics since then.patient had intake of 90ml of alcohol in the morning and came to home , his daughter was preparing the sweet at 1pm and he came to his daughter to take his phone , for calling his son, had step on the fire wood and suddenly oil fell on his face and had burns on his entire face, admitted under surgery department and after admission patient had pain abdomen, where serum amylase and lipase was elevated and case was taken over by medicine department.
HISTORY OF PAST ILLNESS:
Patient is a known case of diabetes (since 3years for which he is on vildagliptin and metformin medication)
Not a known case of hypertension, asthma, epilepsy, tuberculosis,CAD
No history of previous surgery
FAMILY HISTORY:No significant family history
PERSONAL HISTORY:
Married,2 girl children and a male child
Appetite:normal
Diet: mixed
Sleep: adequate
Bowel and bladder: normal
Addictions: alcoholic(90ml per day) since 30years,smoking (5-6 cigars per day)
Drug history: not allergic to known drugs
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.
VITALS:
Built:moderate
Temperature: afebrile
Pulse rate:78bpm
Bp:140/80 mm Hg
Respiratory rate:16 cpm
SpO2:98%
SYSTEMIC EXAMINATION:
ABDOMEN:
INSPECTION:
Shape:distended
Flanks:free
Umbilicus: central &inverted
no scars,
No dilated veins
Movements are normal
No visible pulsations
Cullens sign-negative
Gray turners sign-negative
PALPATION:
no rise of temperature
tenderness in the epigastric region
Kidney and spleen not palpable
no palpable mass
PERCUSSION:
Shifting dullness seen
AUSCULTATION:
bowel sounds heard
No bruit
RESPIRATORY:
INSPECTION: Chest: symmetrical
Trachea:central
No drooping of shoulders,
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:
no LOCAL rise of temperature.
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:
Concious
Speech:normal
Gait: normal
No signs of neck stiffness
Sensory system :normal
Motor system: normal
Provisional diagnosis:
Superficial facial burns
acute pancreatitis
gastritis
Investigations :
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
