33 year Male with pain abdomen

33 year old male, pain in epigastric region since 4 days (11/9/23)

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I’ve been assigned this case as an intern in an attempt to understand the topic of ‘patient clinical data analysis’ to improve my competency in reading and comprehending the clinical data including history, clinical findings, investigations and come up with a diagnosis and the treatment plan.

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.

CASE SCENARIO : 

A 33yr old male, resident of ramannapet, painter by occupation, came to the OPD with chief complaints of Pain in abdomen since 4 days.

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 4days ago when he developed pain in the epigastric region, which was of colicky type, radiating to the back. The pain aggravated on food or water intake, relieved on bending forward.

The pain was associated with an episode of vomiting which was of projectile type, non bilious and wi5 water as its content.

The patient consumed alcohol 4 days ago

No history of trauma to the abdomen, fever, diarrhoea, constipation, Malena, cough, SOB, burning micturition, reduced urine output.

PAST HISTORY : Similar complaints 6 and 2 years back

6 years ago he developed similar abdominal pain and visited a local physician and was prescribed medication. The pain subsided on the usage of medication 

Then again 2 years ago he had similar complaints and visited KIMS. The pain subsided after usage of prescribed medication.

He is N/K/C/O HTN, DM, TB, CVD, Asthma, Epilepsy, Thyroid disorders, Blood transfusions.

 PERSONAL HISTORY : The patient is married. A painter by occupation. His diet is mixed and his appetite is decreased since 3 days which was otherwise normal.

 His sleep is adequate  

 Has regular bowel movements   

 Micturition is normal 

 No known allergies

Occasionally consumes alcohol since 10 years.

 FAMILY HISTORY : No significant family history

 

 GENERAL EXAMINATION : 

 The patient was informed about the examination and prior consent was  taken. The examination was done in both supine and sitting position in a well lit room.

The patient was conscious, coherent, co operative 

 - well oriented to time and place

 - well built and adequately nourished 

 - no pallor

 - no icterus 

 - no cyanosis

 - no clubbing of fingers

 - lymphadenopathy 

 - no pedal edema 

 - no malnutrition 

 - no malnutrition 

 - no signs of dehydration 

VITALS : 

 Temp - afebrile

 Pulse rate - 86 bpm, regular rhythm, normal volume

 Respiratory rate - 18cpm

 BP - 120/90 mmhg

 SpO2 - 98% at RA 

SYSTEMIC EXAMINATION : 

 Cardiovascular System 

 - no thrills

 - cardiac sounds S1 and S2 heard

 - no cardiac murmurs 

 Respiratory System 

 - no dyspnea

 - no wheeze

 - tracheal position is central

 - breath sounds : vesicular 

 - no adventitious sounds heard

 Abdomen 

 - tenderness present (in the epigastric region)

 - shape : scaphoid

 - no scars, striae or engorged veins 

 - bowel sounds heard

 - no bruits, rubs

 - no shifting dullness

 - no fluid thrill

 - no palpable mass

 - hernia orifices : normal

 - liver: not palpable

 - spleen : not palpable

CNS 

 - conscious

 - normal speech

 - cranial nerves

 - motor and sensory systems normal

 LAB INVESTIGATIONS

PROVISIONAL DIAGNOSIS :

ACUTE PANCREATITIS 

Course in the hospital 

11/9/23

1. The patient is restricted from enteric diet

2. IVF NS/RL/DNS 75ml/hr

3. Inj TRAMADOL 1amp in 100 ml of NS IV/SOS

4. Inj PAN 40mg IV/OD 

5. Inj THIAMINE 1 amp in 100 ml NS  IV/OD

12/9/23

1. The patient is restricted from enteric diet

2. IVF NS/RL/DNS 75ml/hr

3. Inj TRAMADOL 1amp in 100 ml of NS IV/SOS

4. Inj PAN 40mg IV/OD 

5. Inj THIAMINE 1 amp in 100 ml NS  IV/OD

6. Tab CINOD 10mg PO/BD

7. BP, PR monitored

13/9/23

S : patient is asymptomatic as of today, abdominal pain subsided.

O : 

PR - 80bpm

BP - 150/100 mmhg

CVS - S1 S2 heard, no murmurs

RS - Bilateral airways entry present 

        NVBS

P/A - soft, non tender

CNS - NO Focal neurological deficits

A : 

1) Acute on chronic Pancreatitis 

2) De novo hypertension 

3) Alcohol and Tobacco dependence Syndrome

P : 

1.patient allowed on oral fluids and soft diet

2. IVF NS/RL/DNS 75ml/hr

3. Inj TRAMADOL 1amp in 100 ml of NS IV/SOS

4. Inj PAN 40mg IV/OD 

5. Inj THIAMINE 1 amp in 100 ml NS  IV/OD

6. Tab CINOD 10mg PO/BD

7. BP, PR 2nd hourly monitoring