CASE OF A 40Y/M WITH PAIN ABDOMEN & VOMITINGS

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 diagnosis and treatment plan.

CASE:

A 40 year old male tractor driver by occupation came to the opd with the chief complaints of pain abdomen since 3 days
and vomiting since 2 days.

History of present illness :
patient was apparently asymptomatic 3 days back then he developed epigastric pain which is sudden in onset, non radiating, gradually progressive, aggravated after taking food and relieved after vomitings. patient also had vomitings which is 10 to 18 episodes per day ,non bilious, non projectile, non blood tinged, non foul smelling with food particles as context. 

No h/o fever , burning micturition , loose stools, malena .

PAST HISTORY :
Not a k/c/o DM, HTN , TB ,Asthama ,CVA/CAD , EPILEPSY and thyroid
no significant surgical history
no transfusion of blood

PERSONAL HISTORY:
Diet: mixed
Appetite decreased
Sleep adequate
Bowel and bladder movements regular
Chronic alcoholic since 15 years

GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative 
Moderately built and moderately nourished & dehydrated
No pallor,icterus,clubbing,cyanosis,koilonychia,edema and lymphadenopathy 

VITALS:
Temp: 100 F 
PR: 98;bpm 
BP: 160/100 mm hg
RR: 24 cpm 
Spo2 - 99% at RA 
GRBS - 110 mg/dl 

SYSTEMIC EXAMINATION :

CVS:
Inspection:
Chest wall is bilaterally symmetrical.
No precordial bulge
No visible pulsations, engorged veins, scars, sinuses

palpation:
JVP: normal
Apex beat: felt in the left 5th intercostal space in the mid clavicular line.

Auscultation:
S1, S2 heard , No murmurs

RESPIRATORY SYSTEM:
Position of trachea: central
Bilateral air entry +
Normal vesicular breath sounds - heard
No added sounds.

PER ABDOMEN:
Abdomen is soft and  tenderness present in the epigastric region .
No organomegaly.
Bowel sounds heard.
No palpable mass or free fluid 

CNS :
Patient is Conscious 
Speech: normal
No signs of Meningeal irritation
Motor & sensory system: normal
Reflexes: present
Cranial nerves: intact

CLINICAL IMAGES:


PROVISIONAL DIAGNOSIS :
ACUTE PANCREATITIS WITH AKI

INVESTIGATIONS :

CXR - PA View

X RAY ABDOMEN & PELVIS
USG ABDOMEN

ECG

TREATMENT GIVEN

DAY 0
1. IVF 500 ml NS, 500 ml RL @150ml/hr 
2.Inj PAN 40 mg IV/OD
3.Inj BUSCOPAN 10 mg IV/sos 
4.NBM till further orders
5.Strict BP monitoring 4th hourly
6.Strict I/o charting
7.GRBS monitoring 
8am.....2pm.....8pm

DAY 1

1. IVF 500 ml NS, 500 ml RL @100ml/hr 
2.Inj PAN 40 mg IV/OD
3.Inj BUSCOPAN 10 mg IV/sos 
4.NBM till further orders
5.Strict BP monitoring 4th hourly
6.Strict I/o charting
7.GRBS monitoring 
8am.....2pm.....8pm


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