FINAL PRACTICAL EXAM SHORT CASE

 A 27 years old male with pain abdomen.

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CASE:

A 27 years male patient electrician by occupation came with 

CHIEF COMPLAINTS:

Pain abdomen since 3 months .

HISTORY OF PRESENT ILLNESS:

Patient was apparently a symptomatic 3 months back, then he had a blunt trauma where his relatives had beaten him with stick at the left hypochondrium region later which he developed mild diffuse abdominal pain associated with projectile, bilious vomiting, containing food particles , pain relived on taking medications and reocurred after few days at the same region and was radiating to back , then he went to government hospital and received treatment but the symptoms didn't subsided so he went to a private hospital we he took treatment admist of treatment , he tested COVID postive went into home isolation , were he approached a local rmp for the pain abdomen and COVID treatment.

After 5 days he tested negative in mid of January so he went back to the same private hospital and got treated and his symptoms resolved, and was informed about chances of recurrence.

CECT impression done on 1/12 /2021: Pancreatitis with pseudo cyst.

He was symptoms free for few days then he again developed pain 3 days later he came to our hospital with the cheif complaints of pain abdomen at the hypochondrium and epigastric region which is intermittent , squeezing type of pain, radiating to the back where there is the pricking type of pain and the pain radiating to the left shoulder tip ; aggrevated with walking, sleeping, after a prolonged duration of sitting and relieved when he bends forward.

PAST HISTORY:

No similar complaints in past.

Not a k/c/o DM, HTN, ASTHMA, Epilepsy,CAD.

No previous surgical history.

PERSONAL HISTORY:

1. Diet : mixed 
2. Appetite : decreasd since 10 days 
3. Sleep : inadequate 
4. Bowel & bladder : regular 
5. Addictions :- h/o alcohol consumption for 5 years 4months ago.

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 was well nourished and moderately built.

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

VITALS:

1. Temp: Afebrile 
2. BP: 100/80 mm hg
3. PR: 84bpm
4. Rr: 16cpm
5. Spo2: 99% on RA
6. Grbs : 102

SYSTEMIC EXAMINATION:

• RS- Bilateral air present 
• CVS -S1 S2 +; No Murmurs.
• PER ABDOMEN - 

1. Tenderness present in epigastric region and left hypochondrium 
2. Rigidity present in the epigastric region and left hypochondrium 
3. No gaurding
4. Bowel sounds +

• CNS:- NAD 

INVESTIGATIONS:

1.HEMOGRAM -

• HB- 10.5 /DL 
• TLC- 10,500 
• N/L/E/M/B- 135/20/40/05/00
• PCV- 32.5 
• MCV- 82.7 
• MCHC- 32.6 
• RBC- 3.93 
• PLT- 5.5 

2.CUE :- 

• ALBUMIN. NIL 
• BILE SALTS AND PIGMENTS NIL
• PUS CELLS NIL 

3.LFT :- 

• TB 0.48 MG/DL
• DB 0.17 MG/DL
• SGOT 13 IU/L 
• SGPT. 14 IU/L 
• ALP. # 291 IU/L
• Tp. # 5.9 gm/dl 
• albumin. #2.92 gm/dl 
• A/G RATIO. 0.98 

4.SERUM AMYLASE: 292 

5.SEROLGY: NEGATIVE 

6.CRP: POSITIVE 2.4 mg/dL

7. CECT

8. ECG

9.USG ABDOMEN

PROVISIONAL DIAGNOSIS:

CHRONIC PANCREATITIS WITH PSEUDOCYST .

TREATMENT:

1) IVF NS /RL @75 ml / hr 

2) Inj Tramadol 100 ml IV /TID 

3) Inj pantop 40 mg iv/ OD 

4 ) Inj zofer 4 mg iv/sos.

5)Syrup. Cremaffin plus 15/ml/po.