60 YEAR OLD MALE WITH PAIN ABDOMEN

 SUDHAMSHI REDDY M

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 

60 year old male came with complaints of

Pain abdomen since 3 days

Vomitings since 2 days

HOPI:

Patient was apparently asymptomatic 1 year ago, from then he had pain abdomen once a month for which he consulted local doctor and took treatment.

Patient now presented with complaints of pain abdomen since 3 days- Umbilicus, left hypochondrium and left lumbar region.

Non radiating,pain is severe and relieved on bending forward.

Vomitings since 2 days- 3 episodes/ day, food particles as content, non bilious, non projectile, not blood stained.

No H/O fever, loose stools.

PAST HISTORY:

Not a K/C/O HTN, DM,TB, ASTHMA,EPILEPSY,THYROID DISORDERS.

PERSONAL HISTORY:

Appetite normal

Diet mixed

Sleep normal

Bowel and bladder regular

Alcoholic consumes 90ml daily 

Smoker- stopped 3 years ago.

GENERAL EXAMINATION:

Patient is conscious, coherent ,cooperative

Afebrile on touch

PR : 88bpm

RR : 20cpn

BP : 140/90mm of hg

Spo2: on 97% on RA

Grbs : 183mg/dl

SYSTEMIC EXAMINATION:

RS: BAE NVBS no added sounds

CVS : S1 S2 heard no murmurs

P/A : soft , non tender

CNS : higher mental functions intact

Tone normal in all 4 limbs

Power 5/5 in all limbs

All reflexes present

INVESTIGATIONS:

Hb- 16

PCV- 50.1

TLC- 15,700

PLT- 1.56

Blood urea-44

Serum creatinine- 1.4

Na- 137

K- 4.3

CL-102

LFT

Tb- 1.84

Db- 0.75

SGOT-65

SGPT-29

ALP- 223

TP- 7.3

ALB- 3.63

A/G- 0.99

CUE- albumin+

Serum amylase- 650

Serum lipase- 238

USG ABDOMEN-

Impression: 

-Pancreas head appears bulky measuring 20mm with heterogenous echo texture

-Rest of pancreas is obscured by bowel gas likely Acute pancreatitis

- Visualised bowel loops appears normal and not dilated.

CXR-

ECG-

PROVISIONAL DIAGNOSIS:

ACUTE PANCREATITIS 

TREATMENT:

1. NBM TILL FURTHER ORDERS

2. IVF 1 UNIT RL

            1 UNIT NS

            1 UNIT DNS @ 100ml/hr 

3. INJ TRAMADOL 1AMP IN 100ml NS IV TID

4.INJ THIAMINE 200mg in 100ml NS TID.