CASE OF 40YR/M WITH CHIEF COMPLAINTS OF PAIN ABDOMEN, NAUSEA AND VOMITING

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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.

 

CHIEF COMPLAINTS: 

      A 40 yr old male resident of krishnapuram, nalgonda dist, field assistant by occupation presented with the chief complaints of:

•   pain abdomen since 3days
•   nausea and vomiting since 3days 

HISTORY OF PRESENTING ILLNESS:

      Patient was apparently asymptomatic 3 days ago, then he developed pain in abdomen of epigastric region and left lumbar region which is squeezing type, constant, radiating to the back and aggravated on bending forward on the first day of pain and non radiating,not aggravated with positional change now.

He developed nausea and vomiting which was 10-15 episodes which was non bilious, non projectile and food as content.

no history of fever, shortness of breath, cough

 

PAST HISTORY :

    history of diabetes since 10years

    history of hypertension since 8 years

    no history of asthma,TB,epilepsy and thyroid disorders.

PERSONAL HISTORY:

   Appetite: decreased

   Diet: mixed

   Sleep: disturbed

   Bowel and Bladder: regular 

   Addictions: history of alcohol intake for 5 years

DAILY ROUTINE:

  He works as a field assistant under NREGS, nalgonda from last 15 years, he supervises around 200-250 workers daily. He goes to his work on his bike at 9 in the morning and comes back home around 5 in the evening.

 Since 5 years, the work stress made him to take alcohol with his colleagues from the work and consumes 200-250ml of whiskey on a daily basis

                       5 years ago- started drinking alcohol

                                         ↓

                       3 years ago- admitted in a hospital with the similar complaints, got treated                           and discharged after 5 days

                                         ↓

                      since 5 days, he couldn't cope up the work stress,consuming alcohol continuously, skipping food and not going to home

                                         ↓

                      developed pain abdomen and nausea,vomiting

 

FAMILY HISTORY:

 

TREATMENT HISTORY: 

• INJ. HAI 2 times a day (used metformin+glimiperide before)
  
• TAB.AMLODIPINE 5mg daily

GENERAL EXAMINATION:

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

      Pallor - Absent

      Icterus - Absent

     Clubbing - Absent

     Cyanosis - Absent

     Lymphadenopathy -Absent

VITALS:

      PR - 104beats per min

      RR - 18 cycles per min

      BP -  160/100 mm of Hg

     Temp -99 F

SYSTEMIC EXAMINATION:

    CVS- S1,S2 heard and no murmurs heard
    Respiratory System - NVBS+, BAE+, trachea central
    Per Abdomen-
              inspection: shape of abdomen- obese
                                 no scars, no sinuses, no hernial orifices
                                 all quadrants are moving equal with respiration

 

              

 

              palpation:liver,spleen both are not palpable 

                              tenderness felt over epigastric,left hypochondriac, left iliac fossa
              percussion- resonant
              auscultation- bowel sounds heard, no audible bruit
   CNS- no focal neurological deficit 

INVESTIGATIONS:

      

                 

             

                            

PROVISIONAL DIAGNOSIS:

             ACUTE PANCREATITIS

MANAGEMENT:

1. NBM 
2. iv fluids NS&RL @125ml/hr
3. Inj.PANTOP 40mg IV BD
4. Inj.Zofer 4mg IV SOS
5. Inj.PIPTAZ 2.25mg IV TID
6. Tab.Amlong 10mg PO OD
7. GRBS every 4th hourly
8. Inj.TRAMADOL 1amp IV  
9. Inj. Human ACTRAPID according to sugars