1801006108 - LONG 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.

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 6 days
nausea and vomiting since 6 days
abdominal distention since 5 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 6 days ago, then he developed pain in abdomen of epigastric region which is severe, squeezing type, constant, radiating to the back and aggravated on doing any activity and relieved on sitting and bending forward.

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

and then he developed abdominal distention 5 days ago which is sudden onset, gradually progressive to current state.

no history of decreased urine output, facial puffiness,edema

no history of fever, shortness of breath, cough

PAST HISTORY :

history of diabetes since 5 years

history of hypertension since 5 years

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

PERSONAL HISTORY:

Appetite: decreased

Diet: mixed

Sleep: adequate

Bowel and Bladder movements : 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 around 60ml 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

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since 5 days, he couldn't cope up the work stress,consuming alcohol continuously taking around 500 ml daily, skipping food and not going to home

↓

developed pain abdomen and nausea,vomiting

FAMILY HISTORY:

History of diabetes to patient's mother since 14 years

History of diabetes to patient's father since 15 years

TREATMENT HISTORY:

metformin plus glimiperide

telmisartan 40 mg

GENERAL EXAMINATION:

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

Adequately built and Adequately nourished

Pallor - Absent

Icterus -Absent

Clubbing - Absent

Cyanosis - Absent

Lymphadenopathy -Absent

Pedal Edema - Absent

Vitals :

Temperature - 99 F

Pulse Rate - 80 beats per minute , Regular Rhythm, Normal In volume, No Radio-Radial or Radio-Femoral Delay

Blood Pressure - 130/90 mmHg measured in the left upper limb, in sitting position.

Respiratory Rate - 13 breaths per minute and regular

SYSTEMIC EXAMINATION:

Patient examined in a well lit room, after taking informed consent.

GASTROINTESTINAL SYSTEM EXAMINATION

Oral Cavity: Normal

Per Abdomen :

Inspection -

Shape - Uniformly Distended

Umbilicus - displaced downwards

Skin - No scars, sinuses, scratch marks, striae, no dilated veins, hernial orifices free, skin over the abdomen is smooth

External genitalia - normal

Palpation -

No local rise in temperature, tenderness in epigastric area

Liver not palpable

Spleen not palpable

Kidneys are not palpable

Abdominal Girth - 84 cm

Xiphisternum - Umbilicus Distance - 21 cm

Umbilicus - Pubic Symphysis Distance - 15 cm

Spino-Umbilical Distance - 19 cm and equal on both sides

Percussion -

Shifting Dullness - Present

Liver dullness at 5th intercoastal space along midclavicular line - Normal

Spleen Percussion - Normal

Tidal Percussion - Absent

Auscultation -

Bowel Sounds - Absent

No Bruit or Venous Hum

CARDIOVASCULAR SYSTEM EXAMINATION

Inspection -

Chest Wall is Symmetrical

Precordial Bulge is not seen

No dilated veins, scars, sinuses

Apical impulse - Not Seen

Jugular Venous Pulse - Not Raised

Palpation -

Apical Impulse - Felt at 5th Intercostal space in the mid clavicular line

No thrills, no dilated veins

Auscultation -

Mitral Area - First and Second Heart Sounds Heard, No other sounds are heard

Tricuspid Area - First and Second Heart Sounds Heard, No other sounds are heard

Pulmonary Area - First and Second Heart Sounds Heard, No other sounds are heard

Aortic Area - First and Second Heart Sounds Heard, No other sounds are heard

RESPIRATORY SYSTEM EXAMINATION

Inspection -

Chest is symmetrical

Trachea is midline

No retractions

No kyphoscoliosis

No Winging of scapula

No Scars, sinuses, Dilated Veins

All areas move equally and symmetrically with respiration

Palpation -

Trachea is Midline

No tenderness, local rise in temperature

Tactile Vocal Fremitus - Present in all 9 areas

Percussion -

Percussion Right                   Left
Supra clavicular: resonant resonant
Infra clavicular:          resonant resonant
Mammary: resonant Resonant
Axillary: resonant    resonant
Infra axillary: resonant    resonant
Supra scapular: resonant            resonant
Infra scapular: resonant resonant
Inter scapular: resonant resonant

No tenderness

Auscultation -

Auscultation:              Right.                   Left

Supra clavicular:.       NVBS                NVBS
Infra clavicular:          NVBS                NVBS
Mammary: NVBS NVBS
Axillary: NVBS                 NVBS
Infra axillary: NVBS         NVBS
Supra scapular:   NVBS NVBS
Infra scapular: NVBS               NVBS
Inter scapular: NVBS               NVBS

No added sounds

Vocal Resonance in all 9 areas- normal

CENTRAL NERVOUS SYSTEM EXAMINATION

All Higher Mental Functions are intact

No Gait Abnormalities

No Bladder Abnormalities

Neck Rigidity Absent

PROVISIONAL DIAGNOSIS: Ascites secondary to pancreatitis

INVESTIGATIONS