45 yr old male with Pain Abdomen
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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.
A 45 ur old male patient resident of gudur carpenter by occupation came with
Chief complaints: Pain in abdomen since 3 days
Constipation since 3 days
Vomitings since 3 days
HOPI: Patient was apparently asymptomatic 3 days back then he developed pain in epigastric region of abdomen which was sudden in onset and gradually progressive which was of pricking type aggravated by eating food and on lying down position and relieved on sitting and bending forward then
He had 3 episodes of vomiting after eating food which was non bilious non projectile non blood tingled and had constipation since 3days
No H/o fever, cough,cold
No H/o diarrhoea,melaena, wt loss
No H/o dysphagia,odynophagia,heart burn, reflux
Past history:
Admitted to hospital with similar complaint of pain abdomen 1 yr back and was diagnosed as acute pancreatitis and was treated
N/k/c/o dm,htn,epilepsy,tb,asthma
Personal history:
Diet-mixed
Appetite normal
Sleep adequate
Bowel and bladder regular
Consumer 1 quarter of alcohol (whiskey) everyday
Family history:
No relevant family history
General examination:
Patient is conscious ,coherent,cooperative well oriented with time place and person moderately built and moderately nourished
No signs of Pallor,icterus,cyanosis,clubbing,lymphadenopathy,edema
Vitals:
Pulse - 76 bpm
BP - 110/80 mm Hg
RR - 18 cpm
Temp- 97.8F
Systemic examination:
P/A:
Inspection:
Abdomen is non distended
Umbilicus inverted
No scars,pulsations,peristalsis,dilated veins
No localised swellings
Palpation:
Soft , tender in epigastric region and has no signs of organomegally
Percussion:
No fluid thrill or shifting dullness
Auscultation:
Decreased bowel sounds of 3-4 /min
Respiratory:
Normal vesicular breath sounds heard
Cvs: s1 s2 heard no murmurs
Cns: no focal neurological deficits
Provisional diagnosis: Acute pancreatitis
Investigations:
Lft:TB- 1.17mg/dl
Db- 0.26mg/dl
Sgot - 45IU/L
Sgpt - 41IU/l
Alp -166IU/L
TP- 6.9 gm/dl
Alb- 4.3 gm/dl
A/G- 1.67
Electrolytes
Na-140K-4.1
CL-102mmol/
lSerum amylase- 841
Serum lipase- 218
Fbs -121mg/d
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