CASE 5: A 34 yr old male with pain Abdomen since 4 days
A 34yr old male came with complaints of pain Abdomen since 4 days.
(Ad. Date: 11/9/23)
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 patients 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.
I've 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 a diagnosis and treatment plan.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.
CASE SCENARIO:
A 34yr old male resident of ramanapet , painter by occupation, came to the OPD with the cheif complaints of
- pain Abdomen since last 4 days.
HISTORY OF PRESENT ILLNESS:
- The patient was apparently asymptomatic 6 years ago when he developed pain Abdomen, for which he visited a local physician and was prescribed medication. The pain subsided after upon using this medication.
- then 2years ago he had same complaints and visited KIMS. The pain subsided after using the prescribed medication.
* 4 days ago he developed pain abdomen:
- in the epigastric region, of colicky type, radiating to the back, aggravated by food and water intake, relieved by bending forward.
- pain was also associated with 1 single episode of projectile vomiting, which was non bilious and had water as its content.
--> History of consumption of alcohol 4 days ago.
-->No history of Trauma, fever, diarrhea, constipation, malena, cough, SOB, burning micturition, reduced urine output.
DAILY ROUTINE:
- Before 4 days, he used to wake up at 6:30am, eat rice for breakfast and goes to work as a painter. At 1pm he used to have lunch (rice) at work. He used to complete his work and come back to his house at around 6:30 - 7pm. He usually had dinner (rice) at 8pm and then went to sleep.
- since 4 days, he wakes up at random times between 5 am to 9 am, has meals when given by attender and lies in bed most of the time.
HISTORY OF PAST ILLNESS:
- History of similar complaints present in the past (6 years and 2 years ago)
- N/K/C/O HTN, DM, TB, CVD, Asthma, Epilepsy, Thyroid disorders, blood transfusions.
SURGICAL HISTORY:
- no pervious surgical history.
PERSONAL HISTORY:
- Married
- Painter by occupation
- Mixed diet
- Appetite decreased since 3 days
- Adequate sleep
- Regular bowels
- Normal micturition
- No known allergies
- Occasionally consumes Alcohol (1 beer bottel) since 10 years ago.
FAMILY HISTORY:
No significant family history
GENERAL EXAMINATION:
I have examined the patient after taking prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room.
- patient was conscious, coherent and cooperative
- well oriented to time and space
- well built and adequately nourished
- no pallor
- no icterus
- no cyanosis
- no clubbing of fingers
- no lymphadenopathy
- no pedal edema
- no malnutrition
- no dehydration
VITALS:
- Temperature: afebrile
- Pulse rate: 86 bpm, regular rhythm, normal volume
- Respiratory rate: 18 cpm
- BP: 120/90 mm Hg
- 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
- trachea position: central
- breath sounds: vesicular
- no adventitious sounds heard
Abdomen
- tenderness present (in the epigastric region)
- shape: scaphoid
- no scars, striae, engorged veins
- bowel sounds heard
- no bruits, rubs
- no shifting of dullness
- no fluid thrill
- no palpable mass
- hernia orifices: normal
- liver: not palpable
- spleen : not palpable
Central Nervous System
- conscious
- normal speech
- cranial nerves normal
- motor and sensory systems normal
INVESTIGATIONS:
HEMOGRAM
PROTHROMBIN TIME:
BLEEDING AND CLOTTING TIME:
ACTIVATED PARTIAL THROMBOPLASTIN TIME:
SERUM MAGNESIUM:
SERUM ELECTROLYTES:
BLOOD UREA:
SERUM CREATININE:
LIPASE:
SERUM AMYLASE:
PROVISIONAL DIAGNOSIS:
Acute pancreatitis
TREATMENT:
INJ. tramadol I.V
INJ. Pantop 40mg I.V
INJ. Zofer 4 mg I.V
I.V Fluids
