A 65 Yr old female with pain abdomen and vomitings since 1week

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A 65 year old female resident of Suryapet, homemaker, came to medicine OPD with

 CHIEF COMPLAINTS:

C/O PAIN ABDOMEN SINCE 14DAYS

C/O VOMITINGS 7DAYS AGO

HISTORY OF PRESENTING ILLNESS:

PATIENT WAS APPARENTLY ASYMPTOMATIC 20

DAYS AGO THEN SHE HAD H/O

FEVER.HIGH GRADE ASSOCIATED WITH CHILLS AND RIGORS THAT RELIEVED AFTER TAKING MEDICATION 5-GDAYS AFTER GETTING RELIEVED FROM FEVER. SHE HAD C/O ABDOMINAL PAIN AT EPIGASTRIC AND RIGHT HYPOCHONDRIUM REGION. SPASMODIC TYPE,NON RADIATING, NO AGGREVATING AND RELIEVING FACTORS, IT WAS ASSOCIATED WITH NON BILIOUS, NON PROJECTILE VOMITING, NON BLOOD.NON MUCOID IN NATURE.AFTER 5DAYS PATIENT BOUGHT FOR CONSULTATION AND TREATED SYMPTOMATICALLY.

PAST HISTORY:

H/O TYPHOID FEVER 20 DAYS AGO(6DAYS OF ILLNESS)

N/K/C/O HTN.DM2.TB,EPILEPSY,CAD.CA,THYROID ABNORMALITIES

FAMILY HISTORY:

NO SIGNIFICANT FAMILY HISTORY

PERSONAL HISTORY:

DIET-MIXED

APPETITE -NORMAL

SLEEP -ADEQUATE

BOWEL AND BLADDER MOVEMENTS-REGULAR

ADDICTIONS-NONE

DAILY ROUTINE:

PATIENT WAKES UP AT 5AM DOES HER HOUSEHOLD CHORES AND HAS BREAKFAST AROUND 7AM. THEN SHE WILL CONTINUE HER DAILY HOUSEHOLD CHORES AND HAS HER LUNCH BY 1PM, REST FOR AN HOUR THEN SHE WATCHES TV AND HAS DINNER AT AROUND 7:30PM,GOES TO SLEEP AROUND 9PM.

HER DAILY ROUTINE IS NOT AFFECTED.

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE

NO SIGNS OF PALL OR ICTERUS, CYANOSIS,CLUBBING EDEMA LYMPHADENOPATHY

VITALS:

PR-76BPM

BP-120/70 MMHG

CVS:S1 S2 HEARD,NO MURMURS

RS:BAE+

CNS:HMF INTACT,NFND

P/A: SOFT,NON TENDER

GASTROENTEROLOGY REFERRAL DONE ON 05/09/23 AND 

ADVICED MRCP I/V/O DILATED CBD,

UGIE HAS BEEN DONE SHOWING NO EVIDENCE OF PERI-AMPULLARY GROWTH.

SURGERY REFERRAL DONE ON 05/09/23 AND DIAGNOSED AS ADENOMYOMATOSIS OF GALL BLADDER WITH DILATED CBD AND MPD WITH IHBRD AND AND ADVISED TAB UDILIV

300MG PO/BD X 3 WEEKS AND ALSO ADVISED MRCP

INVESTIGATIONS:

04/09/23

HEMOGRAM:

HB-10.8

PCV-34.6

TLC-7310

PLT COUNT-2.94

BLOOD UREA-17

S.CREATININE-0.8

NA+ 139

K+ 4.1

CL- 101

TB-0. 56

DB-0.20

SGPT-29

SGOT-12

ALP-196

TP-6.9

ALB-3.7

S.AMYLASE-65

S.LIPASE-32

PROVISIONAL DIAGNOSIS:

ADENOMYOMATOSIS OF GALL BLADDER WITH DILATED COMMON BILE DUCT AND MAIN PANCREATIC DUCT WITH INTRA HEPATIC BILIARY  RADICLE DILATATION

USG ABDOMEN:

TREATMENT:

1. TAB.UDILIV 300MG PO/BD
2. TAB.MVT POIOD
3. MONITOR VITALS 4TH HRLY