1801006144 - SHORT CASE

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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.

38 yr male with abdominal pain

CHIEF COMPLAINTS

38 yr old male came to Gm opd with chief complaint of abdominal pain since 5 years

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 5 years ago then he developed pain in upper abdomen which is insidious in onset and gradually progressive,dragging type of pain radiating  to back of thorax.  Initially the pain used to be once in every 6 months but from 6 months the pain occurs once or twice in every month associated with vomiting. Aggravated on taking heavy food and alcohol and relieved temporarily on medication 

On 13th February he had 5 to 6 episodes of vomiting after having food or water. Initially vomitus contain undigested food particals later it contain thick Yellow color fluid.  Vomiting  was associated with weakness. He was treated temporarily in local hospital.

On 1 march he had another episode of pain..temporarily he got treated in local hospital and on 15th he was admitted in our hospital.

PAST HISTORY

No h/o Dm,htn,tuberculosis,epilepsy,asthma,cvd

5 years ago he had abdominal pain  and he was diagnosed as pancreatitis. He was on medication pantoprezole, pancreatin,citrex for 3 months symptoms relieved  for  next 3 months after stopping medication and another episode of abdominal pain followed  by medication for next 3 months...

Since 6 months he is having abdominal pain associated with vomiting weakness

PERSONAL HISTORY

Married 12 yrs ago.. now separated

Diet mixed

Apatite normal

Sleep inadequate 

Bladder regular 

Bowel regular

Addictions 

Alcohol daily approx 180ml to 750ml per day since collage yrs. stopped taking since 6 months

Smoking since 12 years

Initially 1 to 2 cigarettes per day later on 2 packs per day..

Since last year 1 pack per day

No h/o allergies 

FAMILY HISTORY

Not significant 

GENERAL EXAMINATION

PATIENT IS CONSCIOUS COHORENT COOPERATIVE. WELL ORIENTED TO TIME PLACE AND PERSON

MODERATELY BUILT AND MODERATELY NOURISH

NO SIGNS OF PALLOR, ICTERUS, CLUBBING, CYANOSIS, GENERALIZED LYMPHADENOPATHY, EDEMA

VITALS

Bp 110/80

Temp 

Pulse rate 78bpm

Respiratory rate 18cpm

Systemic examination

CVS

S1 s2 heard

RS

18cpm

CNS

No neurological deficit

P/A

Inspection 

No distention

Umbilicus normal 

No sinuses 

A scar on right iliac fossa

Palpation

No local rise in Temperature 

Mild tenderness around left side of umbilicus 

No organomegaly

Percussion 

Tympanic

Auscultation 

Bowel sounds heard

Investigations 

Serum amylase 175 (normal 25 to 140IU/L)

Serum lipase 72 ( normal 13 to 60 IU/L)

Fasting Blood sugar  95 (normal 70 to 110mg/dl)

Liver function test

RENAL function test

Complete Blood picture

Ct

https://youtu.be/9Y8v7uLEMio

https://youtu.be/5Gd1eEkNnrc

Provisional diagnosis

-Chronic pancreatitis secondary to Alcohol 

treatment 

T.ULTRACET 1/2 TABLET