A 32 YEAR OLD MALE WITH PAIN ABDOMEN

 This is an online E-Log book to discuss our patient's de-identified 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 these patient's clinical problems with collective current best evidence-based inputs. This E-log also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are welcome.

CASE: 

A 32 Year old male came to the OPD on 29/10/2021 with Pain Abdomen.


CHIEF COMPLAINTS:

1. Pain abdomen since one day

2. Vomiting since one day (2 episodes)

3. Constipation since one day


HOPI:

Patient was apparently asymptomatic 4years ago (2017) , after which he developed PAIN ABDOMEN and was taken to a local hospital and he was diagnosed with ACUTE PANCREATITIS and treated for the same, was asked to stop consumption of alcohol and discharged.

Patient continued to consume alcohol occasionally.

2021 September- he again developed symptoms and  was taken to hospital and waa treated.

29th October 2021-

Patient came to OPD with

  •  PAIN ABDOMEN-Epigastrium and left hypochondrium since 1 days; squeezing type, Sudden in onset and gradually progressive 

Aggravated on drinking and no relieving factors.

There is no positional and diurnal variation. 

  • VOMITING-associated with nausea and vomiting; 2 episodes, non- projectile, non- bilious, contents are food particles
  • CONSTIPATION- since one day
  • SOB- Grade IV
  • No h/o Fever


PAST HISTORY:

Not a K/C/O - DM, HTN, Epilepsy, Asthma, TB, CVA.


PERSONAL HISTORY: 

  1. Diet- MixedA
  2. ppetite- Loss of appetite is present.
  3. Bowel and bladder movements- Regular
  4. Sleep- Adequate
  5. Addictions- H/o alcohol consumption (beer) since 5 years, 2 times a day, stopped 1 month ago.
  6. Surgical history: no h/o previous surgeries.

FAMILY HISTORY:

Insignificant 

GENERAL EXAMINATION:

The patient was examined in a well-lit room after informed consent was taken.

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

He is well nourished and moderately built.

No Pallor, Icterus, Clubbing, Cyanosis, Koilonychia, Lymphadenopathy, Edema.


VITALS:

  1. Temperature- Afebrile
  2. PR- 90 bpm
  3. RR- 18 cpm
  4. BP- 100/70 mmHg

SYSTEMIC EXAMINATION:


  1. CVS: S1, S2 Heard
  2. RS: BAE+, NVBS
  3. P/A: shape- scaphoid, soft, tenderness is present in the epigastric region., Bowel sounds heard, no palpable mass, no free fluid, no bruit.
  4. CNS: Intact


INVESTIGATIONS:

COMPLETE BLOOD PICTURE


SERUM AMYLASE


SERUM LIPASE


COMPLETE URINE EXAMINATION


SERUM ELECTROLYTES


SERUM CREATININE


LIVER FUNCTION TEST


LDH


BLOOD UREA


SERUM CREATININE


HIV TEST REPORT


HEPATITIS B


HEPATITIS C


ULTRASOUND 


ECG


HEMOGRAM


COLOUR DOPPLER 2D ECHO


PROVISIONAL DIAGNOSIS:

Acute Pancreatitis 2° Alcohol

TREATMENT:

  1. IVF- NS,RL-150ML/HR
  2. INJ.PAN.40MG/IV/BD
  3. INJ. THIAMINE 200MG IN 100ML NS /IV/BD
  4. INJ.OPTINEURON 1AMP IN 100ML NS/IV/OD
  5. INJ.TRAMADOL 1AMP IN 100 ML NS/IV / B
  6. INJ.ZOFER 4MG /IV/BD
  7.   strict I/O monitoring 
  8. BP,PR, SPO2 Monitoring 4th helt
  9. GRBS monitoring 6hrly
  10. inform sos



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