32 yr old male with acute pancreatitis
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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 and comprehending clinical data including history,clinical finding investigations and come up with a diagnosis and treatment plan.
A 32 year old male patient came with
Chief complaints:
Pain abdomen in the epigastric region since 10 days
Vomitings 5 days ago
Cold since 6 days
Cough since 5 days
HOPI:
Patient was apparently asymptomatic 10 days ago, then developec abdominal pain in the epigastric region which is intermittent, aggrevated on palpation and relieved on medication and got checked up at an RMP clinic, where medication was given along with fluids and it was relieved. Later the same night he experienced another episode of similar type of pain after which he got admitted in suryapet and underwent investigations. He was diagnosed with pancreatitis and liver cirrhosis for which he underwent treatment for 2 days followed by discharge.
There were 2 episodes of vomiting which is non-projectile and non-blood stained. Content is food particles.
Complaints of cold since 6 days and cough since 5 days which is dry type at the beginning, with expectoration after 3 days. There is shortness of breath on rest.
Past history:
7 years ago he went to hospital with complaints of pain in the loin region and decreased Urine output, diagnosed as renal calculi. It was relieved on medication.
3 years ago there was pain in the right hand along with tingling and numbness along the right hand. He was diagnosed with cervical C3 C4 disc compression for which he underwent ayurvedic treatment for 15 days and got relieved.
Personal history:
Diet mixed
Appetite normal
Sleep adequate
Bowel and bladder regular
He is an alcoholic since 15 years, daily 180ml/day and chews tobacco since 15 years ,1 packet/day. Last binge was 1 week ago.
Not a k/c/o HTN, DM, ASTHMA, TB, EPILEPSY, CAD ,CVA.
General examination
Patient is c/c/c
No pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.
VITALS
Temp-Afebrile
BP- 110/70
PR - 80
RR - 18
CVS - S1 S2 heard
R/S : INSPECTION
shape - scaphoid
No wheeze
No scars , sinuses present.
PALPATION
no palpable mass,
Trachea- central
AUSCULTATION
Vesicular breath sounds
decreased breath sounds in right infra scapular and infra axillary area
No dyspnea, no rhonchi.
P/A -
INSPECTION - obese abdomen, there are no scars ,sinuses , no distension, no eversion of umbilicus.
PALPATION - girth - 113 cm
Tenderness on right iliac fossa, rt lumbar region, rt hypochondrial epigastric region.
No palpable liver and spleen.
CNS - NFND
USG REPORT
Diagnosis
Acute interstitial pancreatitis secondary to alcohol consumption with bilateral pleural effusion with grade 1 fatty liver.
Treatment
1. Inf NS+ RL @75ml/hr
2. Inj. Pan 40mg IV/OD
3. Inj. Optineuron 1 amp in 100ml NS/IV/OD over 30min.
4. O2 inhalation
5. Tab. Ultracet PO/BD
6. Inj. Tramadol 1amp in 100ml NS / IV/sos
7. Allow liquid diet if tolerated start to solid diet.
8 vital monitoring
9. Strict input/output monitoring.
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