1802102020- LONG CASE

  This is an online E- log book to discuss our patient's de- identified health data shared informed 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 centered online learning portfolio and your valuable inputs on comment box is welcome."

A 36 year old male patient came to OPD with chief complaints of pain in the abdomen since 45 days.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 45 days  back and then  he noticed pain in the abdomen that is in the epigastric region. It is associated with nausea and loss of appetite.

No history of vomitings.

No history of constipation. 

No history of jaundice.

PAST HISTORY:

No history of diabetes,  hypertension, CAD, asthma, TB, epilepsy, thyroid disorders. 

No history of any surgeries in the past. 

No history of similar complaints in the past. 

PERSONAL HISTORY:

Appetite: low

Diet: mixed 

Sleep: inadequate 

Bowel and bladder movements: regular 

Micturition: normal

Addictions: 

 Alcohol consumption- regular

Toddy since 15 years

Whisky 250 ml once in 2 days for 1 year.

FAMILY HISTORY:

No member of the family had similar complaints. 

TREATMENT HISTORY:

Patient had not undergone any treatment prior. 

He is not allegic to any known drugs. 

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative and well oriented to time, place and person. 

There is no signs of  pallor, icterus, cyanosis, clubbing and generalised lymphadenopathy. 

VITALS:

Temperature: afebrile

Blood pressure:  110/ 80 mm Hg

Pulse rate:  90 beats / min

Respiratory rate: 20/ min

Spo2 : 97% at room temperature 

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

No thrills 

S1 and S2 sounds are heard 

No cardiac murmurs

RESPIRATORY SYSTEM:

Dyspnoea- no

No wheezing sounds 

Position of trachea- central 

Breath sounds- vesicular 

ABDOMEN:

Shape of abdomen- scaphoid 

Tenderness- no 

Palpable mass- no 

Hernial orifices- normal 

Free fluid- no 

Bruits- no 

Liver - not palpable

Spleen- not palpable

Bowel sounds- yes 

CENTRAL NERVOUS SYSTEM:

Level of consciousness: conscious 

Speech: normal 

Signs of meningeal irritation

Neck stiffness- no 

Cranial nerves- normal 

Motor system- normal 

Sensory system- normal 

INVESTIGATIONS:

               COMPLETE URINE EXAMINATION 



LIVER FUNCTION TEST 

                  

 Amylase and lipase- mildly elevated

HBsAg- ELISA 

SERUM CREATININE 

BLOOD UREA 



ANTI HCV ANTIBODIES- RAPID




BLEEDING AND CLOTTING TIME

     



SERUM ELECTROLYTES 




             
COMPLETE BLOOD PICTURE 
            

                    
 HIV 1 and 2 ELISA















 


                               ECG


PROVISIONAL DIAGNOSIS:

Acute pancreatitis 

TREATMENT:

1. IVF - NS/RL/DNS- 100 ml / hr

2. Inj. PAN 40 mg IV/OD

3. Inj. ZOFER 4 mg/ IV/ SOS

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

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

6. Monitor vitals and inform SOS.











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