45yr Male with Abdominal pain

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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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan

CONSENT AND DEIDENTIFICATION : 

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 through out the piece of work whomsoever .

PRESENTING COMPLAINTS:

Severe pain in abdomen 

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 1 month back and then he developed  severe pain abdomen which was sudden in onset for which he went to RMP doctor and pain subsided after taking medication for 2 days 

. Again he developed sudden pain in abdomen 1 week back in the epigastric and right hypochondriac region radiating to backside dragging type of pain, no aggrevating or relieving factors

. Associated with 2 episodes of vomiting 

. No h/o fever, headache, burning micturition, chest pain , breathlessness

PAST ILLNESS:

. Known case of HTN from 3 years ( 40 mg telmisartan)

   but he doesn't take it regularly 

. Not k/c/o DM, TB , Asthma, Epilepsy,  CAD, CVA

PERSONAL HISTORY:

Diet- mixed

Appetite- decreased appetite since 1 year

Sleep- normal 

Bowel and bladder movements- regular 

Addictions- regular alcohol consumption since 30years

FAMILY HISTORY 

.No significant Family history 

.No known allergic history 

GENERAL EXAMINATION:

. The patient is conscious,  coherent, cooperative 

. Well nourished and Moderately built 

. No pallor, icterus, cyanosis, clubbing, lymphadenopathy, Pedal edema 

VITALS:

Pulse rate - 82 bpm

Respiratory rate - 16 cpm

Blood pressure - 130/80 mmHg

Temperature - Afebrile 

SYSTEMIC EXAMINATION :

CVS : 

S1 and S2 heart sounds heard

NO murmurs 

RESPIRATORY SYSTEM : 

Bilateral air entry present             

position of trachea - central 

NVBS

No added sounds

No dyspnea

CNS :

No focal and neurological deficits

HMF -Normal

Pupils- Bilateral PSNL

                      Upper limb                        Lower limb

               Right             Left                  Right          Left

Tone:      Normal        Normal            Normal      Normal

Power:           5/5           5/5                   5/5              5/5

Reflexes:         Right             Left

Biceps              +                    +

Triceps            +                     +

Supinator         +                    +

Knee                +                   +

Ankle               +                  +

Plantar         Flexion        Flexion

PER ABDOMEN :

Inspection- 

Umbilicus is central and inverted 

•No engorged veins, scars seen 

Palpation- 

. Tenderness felt in epigastric and right hypochondriac region and right lumbar region

Percussion: 

•No free fluid 

 

LAB INVESTIGATIONS :

Hemogram

Complete Urine examination 

LFT 

RFT

Lipase 

Amylase 

USG abdomen:

ECG:

PROVISIONAL DIAGNOSIS:

Acute Pancreatitis 

TREATMENT:

. IVF - NS, RL

. INJ Tramadol 100mg in 100ml NS over 1hr IV/BD

. Tab PAN 40mg PO/OD

. Tab Telmisartan 40mg PO/OD

. INJ Thiamine 100mg in 100 ml iv/ BD