55 year old male with pain abdomen


This is an 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 patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments 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 a diagnosis and treatment plan.

CHIEF COMPLAINT:

55 yr old male patient , who is cook by occupation came to casuality with a

• C/O pain in upper abdomen since yesterday morning.

• Vomitings since yesterday morning.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic till yesterday 

•Later he developed pain in upper abdomen Which was sudden in onset Progressive and non radiating , aggrevated on leaning forward, not relieved on medication.

H/O Vomiting since  morning 5-6 episodes,water as content,non projective ,non bilious.

No H/O fever, constipation, loose stools

Patient started drinking alcohol 15yrs back ,he consumes 90ml daily at night. 

HISTORY OF PAST ILLNESS:

N/K/C/O HTN,DM,CAD,TB,epilepsy,Asthama

No past surgical history 

PERSONAL HISTORY:

Appetite-normal

Diet-mixed

Bowel and bladder Movement-Regular

No allergies 

Alcoholic regularly

 GENERAL EXAMINATION:

patient is Conscious,coherent and cooperative 

-No pallor

-No icterus

-No lymphadenopathy

-No cyanosis

-No clubbing of fingers 

VITALS:

Temperature-afebrile

Pulse rate -90 bpm

Respiration rate -16cpm

Bp-110/80 mm Hg

Spo -98% at room air .










ABDOMINAL EXAMINATION:

Umbilicus inverted , No abdominal distention,no  visible pulsations and swelling.

PALPATION:   Soft, tenderness in epigastric region,no guarding,no rigidity, no organo megaly.

 AUSCULTATION:

BOWEL SOUNDS HEARD


RESPIRATORY SYSTEM:

    Shape of chest is elliptical, b/l symmetrical.

    Trachea is central. Expansion of chest is symmetrical

      Bilateral Airway Entry - positive

      Normal vesicular breath sounds

CARDIOVASCULAR SYSTEM:

  No visible pulsations, scars, engorged veins.  

JVP no raised.

Apex beat is felt at 5 Intercoastal space medial to mid clavicular line.

  S1 S2 heard . No murmurs.


CNS EXAMINATION: 

No signs of meningeal signs

Cranial nerves: normal

Sensory system: normal

Motor system: normal

Reflexes: Right.     Left. 

Biceps.      ++.          ++

Triceps.    ++.          ++

Supinator ++.         ++

Knee.         ++.         ++

Ankle        ++.         ++

Gait: normal.


INVESTIGATIONS:






DIAGNOSIS: ACUTE PANCREATITIS 


TREATMENT:  

1. NBM TILL FURTHER ORDERS.

2.IVF NS FLUIDS @75ml/hr.

3.INJ.THIAMINE 200 mg IV/BD IN 100ML NS OVER 30 MINS 

4.INJ.OPTINEURON IN 100ML NS IV/OD OVER 30 MINS.

5.INJ.PAN IV/OD

6.INJ TRAMADOL IV/BD IN 100ML NS OVER 30 MINS 





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