A 38year old male with pain abdomen, vomitings and constipation.

SUDHAMSHI REDDY M

MBBS 9th semester

Roll no:80

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .

 

I’ve 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 diagnosis .

Following is the view of my case..

A 38 year old male with presented to the OPD with chief complaints of

• Pain abdomen since 4 days
• Vomiting since 4 days
• Constipation since 4 days
• Decreased urine output since 3 days

HISTORY OF PRESENTING ILLNESS :

The patient was apparently asymptomatic 4 days back, then consumed alcohol this led to

• Pain abdomen it was sudden in onset in the epigastric region, non radiating, associated with vomiting, pain aggravated on sitting, walking and relieved on lying down.
• Vomiting - food particles as content, non bilious and non projectile.
• Sudden decrease in urine output and he couldn’t pass stools.

PAST HISTORY : 

No history of similar complaints in the past

Not a known case of DM, HTN, TB, Epilepsy

No history of surgeries, blood transfusions.

PERSONAL HISTORY:

Diet: mixed

Appetite: normal

Sleep: adequate

Bowel and bladder movements: reduced

Addictions: consumes alcohol daily for the past 20 years(100-120ml/ day). Betel nut chewing

FAMILY HISTORY:

No history of similar complaints in the family.

No history of Diabetes, Tuberculosis, Stroke, Asthma, any other hereditary diseases in the family.

GENERAL EXAMINATION: 

The patient is examined in a well lit room, with informed consent

The patient is conscious, coherent, cooperative, is well oriented to time, place, person.

She is moderately built and nourished.

Pallor : absent

Icterus : absent

Cyanosis : absent

Clubbing : absent

Lymphadenopathy : absent

Edema : absent

VITALS

Temperature-afebrile

Heart rate-90 beats/min

Blood pressure-110/70 mmHg

Respiratory rate-22 cycles/min

SPO2-98% at room air

SYSTEMIC EXAMINATION:

CVS: S1 and S2 heard

         No added thrills, murmurs

RESPIRATORY SYSTEM: Normal vesicular breath sounds heard, position of trachea central,    no adventitious sounds heard, no dyspnea and wheeze.

PER ABDOMEN: obese, tender, no palpable mass, free fluid present, no organomegaly.

  On auscultation- bowel sounds are not heard 

    

CENTRAL NERVOUS SYSTEM: 

Level of consciousness : conscious to time, place, person

Speech: normal

Cranial nerves -Normal

Motor and sensory: normal 

  INVESTIGATIONS:

  COMPLETE BLOOD PICTURE             

  On the day of admission 

     Hemoglobin - 18.1gm/dl

    Total leukocyte count - 15,300 cells/cumm

    Neutrophils - 87%

    Lymphocytes - 5%

    Eosinophils - 1%

    Platelet count - 2.80 lakhs/cumm

  RENAL FUNCTION TESTS-

   Urea: 29mg/dl
   Creatinine: 0.8mg/dl

   Calcium: 9.9

   Phosphate: 4.1

   Sodium: 136

   Potassium: 3.4

   Chloride: 98

LIVER FUNCTION TESTS-   

Total bilirubin=2.24mg/dl
Direct bilirubin=0.93mg/dl
AST: 57 IU/L
ALT: 113 IU/L
ALP:220 IU/L
Albumin: 4.2
Total Protein:7.2
A/G Ratio:1.40

SERUM AMYLASE: 446 IU/L

SERUM LIPASE: 121ng/dl

    

               

USG ABDOMEN :

PROVISIONAL DIAGNOSIS:

Acute necrotising pancreatitis secondary to alcohol consumption 

TREATMENT REGIMEN:

1. IV - Normal saline , Ringer lactate @150ml/hr
2. Injection PANTOP 40mg / IV / OD
3. Injection ZOFER 4mg / IV / OD
4. Injection TRAMADOL 1 ampoule in 100ml NS 
5. Injection THIAMINE 1 ampoule in 10ml NS IV / TID