1801006060 -SHORT CASE
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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT
Case
A 50 year old male came to opd with
Chief complaints of abdominal pain since yesterday
History of presenting illness
Patient was asymptomatic 1 day ago ,then he developed abdominal pain which is insidious in onset ,gradually progressive in nature ,colicky pain
Pain is continuous and diffuse all over abdomen,more felt in epigastrium.
No aggravating and relieving factors.
No history of radiating pain to back ,nausea,vomiting , constipation ,blood in stools ,loose stools.
He is a chronic alcoholic of 30 yrs
Past history
H/O of diabetes since 3yrs on medication
No h/o of hypertension ,tb,asthma,epilepsy.
Personal history
Daily routine:
He wakes up at 8 am and does his daily routine and is not working ,takes 3 meals daily and drinks alcohol and smokes intermittently through the day and sleeps by 10 pm.
Diet- mixed
Appetite -normal
Bowel and bladder -regular
Sleep-disturbed since yesterday
Addictions -alcohol of 180 ml daily on average
cigarette {tobacco} of 2 to 3 packs daily since 30 yrs
Family history:. Not significant
Treatment history:on anti diabetic medication since 3 yrs
GENERAL PHYSICAL EXAMINATION
Patient is conscious , coherent and co operative
No pallor
Icterus
Clubbing
Cyanosis
Lymphadenopathy
Generalised edema
Vitals
Temp - 37℃
Blood pressure -150/100 mmHg
Pulse rate- 65 bpm
Respiratory rate- 20 bpm
Systemic examination:
Per abdomen examination
On Inspection
Abdomen is obese
Umbilicus is central and inverted
No visible scars/sinuses/engorged viens
All quadrants are moving Uniformly on respiration
Grey turner sign ( discolouration of flanks) and Cullens sign( discolouration of periumbilical area ) are negative [ These are +ve in patients with severe pancreatitis with Haemorrhage ]
On palpation
Inspectory findings are confirmed
Tenderness is seen in epigastrium, left lumbar,right lumbar ,umblical region
No guarding,no rigidity,
No hepatosplenomegaly
On percussion
Liver span is normal
On auscultation
Bowel sounds are heard
CVS examination
S1,S2 heart sounds are heard
Respiratory system examination;
Bilateral normal vesicular breath sounds heard
CNS examination
No focal neurological deficits
Provisional diagnosis:-
Acute pancreatitis secondary to alcohol intake.
Investigations
Haemoglobin :16.2gm/dl{13-17}
Total count:9,300 cells/cumm{4000-10000}
Neutrophils:82%{40-80}
Lymphocytes:10%
Eosinophils :01
Monocytes :07
Basophils :00
MCH :#32.5 pg {27-32}
MCHC:#35.5 %{31.5 -34.5}
Neutrophilia is seen
Complete urine examination
Albumin ++
Sugar+
Pus cells 4-5
Serum electrolyte are normal
Liver function tests
Total bilirubin 1.25
Direct bilirubin 0.52
SGPT 41
SGOT 32
Alkaline phosphate 322
Total protein 7.7
Albumin 4.46
A/G ratio 1.3
Ultra sound findings
Grade 1 fatty liver
Left kidney not visualized in left renal fossa
1.3 mg/dl {0.9- 1.3 mg/dl}
Serum amylase
471 IU/L {25 -410 IU/L}
Random blood sugar
246 mg/dl {100-160mg/dl}
Blood urea
34 mg /dl {12 -42 mg /dl}
Hbs ag - negative
Treatment
Ini pantoprazole 40mg iv
Inj ondansetron 4mg iv stat
Ini diclofenac im stat
Ini buscopan 40 mg im stat
NBM till further
Iv fluids NS ,NL. 100ml/hr
Ini pantoprazole 40 mg iv od
Inj tramadol 1 amp in 100ml NS sos
Inj thiamine 100 mg in 100ml NS /iv/bd
