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CPC MEET

PRESENTATION :SURGERY ‘A’ UNIT

DATE:25-06-2009

Pt by name SubhaRao. Age – 60 years Male.Agriculturist

•      Chief Complaints :-

•      Pain Abdomen – 1 month.

•      Distension of Abdomen on & off – 1 month  (two times.)

•      History of Presenting Illness :-

•      Pt. presented with pain Abdomen – 1 month on & off colicky pain around the umbilical lasts for  30 mins.

•      Relieved on taking medication.

•      Distension of abdomen of On & off – 1 month (two times.)

•      H/O vomiting   bile stained.

•      H/O Constipation

•      Treatment history:

•      Pt. admitted 1 back with the above symptoms Relieved by medical line of Treatment

•      - Ryles tube Aspiration.

•       - IV  fluids.

•       -Antispasmodics,

•      Past History  - No h/o DM, h/o HTN 0r TB.

•      General physical Examination:

•      Male pt. moderately built & nourished.

•             Pulse 84 /min

•             BP – 130/80 mm of Hg

•      P/A:- Distension +,

•               no rigidity ,

•               no guarding

•               B S – Sluggish.

•      SYSTEMIC EXAMINATION :

                                      Normal

•      Clinical Diagnosis :

             Subacute Instestinal obstruction

•      Investigation

•      CBC, Bl Urea, Sr. Creatinine, RBS:            Normal

•      X- Ray Abdomen, & USG – showed small bowel  obstruction

•      Investigation

•      CBC, Bl Urea, Sr. Creatinine, RBS: Normal

•      X- Ray Abdomen, & USG – showed small bowel  obstruction

•      SURGERY

•      Diagnostic Laproscopy followed by Exploratory laprotomy – Done on 17/06/09

•      Inter loop adhesion seen in the jejunal & adhesion to anterior abdominal wall, proximal jejunal loop dialated & distal intestinal loops were Normal. Resection anastamosis done. 

•      Resected Segment Sent for HPR.

Design & Developed by EDP Department, SSIMSRC