35 year old male with pain abdomen and vomitings

   


This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.

Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.


M.Abhignya      8th sem




03/06/21

Case

35 year male pt came to the OPD on 02/06/21 with the chief complaints of :

Pain in upper abdomen since 1 day
vomitings since 1 day



History of present illness


Pt. was apparently asymptomatic 1 day back and then developed  persistent

*Pain in upper abdomen which was sudden in onset ,gradually progressive in

 nature  and it was Throbbing and Sqeezing type 

  -   pain is localized  to EPIGASTRIC and LEFT HYPOCHONDRIAC regions 
                                  and Radiating to Left side of upper back

   -Pain is associated with Vomitings-since 1day
          
        2 episodes   after the intake of toddy 1 day back,vomitings were non-bilious,  non-projectile and  food as the content

*vomitings subsided after treatment from local RMP , but due to persistent pain Pt. came to our hospital for futher management

-No H/O  fever / loose stools/ constipation
-No H/O outside food consumption
-No H/O  burning micturation 
-No H/O trauma
        

Past history

##H/O similar  episode 6 months back , it was relieved after taking treatment from RMP

Not a K/C/O --HTN , T2DM , TB , Asthma , Epilepsy , CAD ,

k/c/o Chronic plaque psoriasis since 18yrs of age

    - Itchy lesions over both lower limbs - they are multiple , well defined , scaly ,           hyperpigmented
     -h/o exacerbation during winters and on intake of alcolol
      -h/o topical medication usage on & off




 
No H/O previous surgeries



Personal history

Diet - mixed 

Appetite - decreased

Bowel and bladder movements - regular

No allergies

Addictions--chronic alcoholic since 3yrs (90-180ml/day)


Family history - not significant 


General Examination

 
The patient is examined with informed consent.

Patient is consious, coherent, cooperative,is well oriented to time,place,person.

He is Moderately Built and nourished.

Pallor : absent
Icterus : absent
Cyanosis : absent
Clubbing : absent
Lymphadenopathy : absent
Edema : absent

VITALS 

Temperature: Afebrile 

Pulse Rate: 110 beats per minute 

Blood pressure: 150/110 mm of Hg 

Respiratory Rate: 12 cycles per minute 

SpO2: 98% on room air

GRBS-147mg/dl

Systemic Examination

on 02.06.21

CVS - S1 and S2 heard
            No added thrills,murmurs

RESPIRATORY SYSTEM - BAE (+)
                                    -  vesicular breath sounds
                                   -  position of trachea -central
                                   -  no dyspnoea and wheeze

PER ABDOMEN : 
    
       shape  -   scaphoid 
       Tenderness -  present in Epigastric & Left hypochondrium 
       No palpable mass
        Guarding and rigidity : ABSENT
       Hernial orifices are Normal
       No free fluid  and bruits
       Liver & Spleen are not palpable 
       Bowel sounds (+)
       Genitals - Normal


 

 CNS  - HMF intact 
             conscious ,oriented to time ,place and person  
             Glasgow scale -15/15


Investigations



Haemogram

CUE

RFT

LFT

ECG

CXR

Serum Amylase

Serum Lipase

 ULTRASOUND REPORT


Impression


*Mild free fluid noted in Perihepatic ,B/L paracolic gutter and pelvic region

*Hyperechoic and enlargedancreas

*Grade 1 fatty liver 

CT






Provisional Diagnosis

Acute Pancreatitis



Treatment   

  

 on 02.06.21


NBM 

IVF -NS , RL , DNS @ 25Oml/hr

INJ. PANTOP 40 mg IV , OD

 INJ. THIAMINE 100 mg in 100 ml NS  IV , TID

 INJ. TRAMADOL in 100 ml NS  IV , BD

INJ. ZOFER 4mg IV/SOS

Tab. PARACETAMOL 500mg PO/SOS

Minitor vitals -4th hourly

Temperature charting













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