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Name: G Sai Manogna
Roll no: 33
I've 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 a diagnosis and treatment plan.
Following is the view of my case :
CASE PRESENTATION:
A 28 year old male who is a resident of Nalgonda has come to the OPD with the chief complaints of
- Pain abdomen since 2 days
- Vomitings since 1 day
History of Presenting illness:
Patient was apparently asymptomatic 2 days ago then he developed pain in the epigastric region after consuming alcohol. It was sudden in onset, increasing in intensity and is of sequezing type. Pain is persistent throughout the day. It later radiated to whole of the abdomen and to the back. Aggrevated with food intake and is relieved on taking medication.
Since 1 day patient had 2 episodes of vomitings, non projectile and is non bilious.
Food particles as contents
No history of fever, giddiness
Past history:
No similar history in the past
Not a known case of Hypertension, Diabetes, Asthma, Tuberculosis
No history of blood transfusions
No history of previous surgeries
Personal history:
Diet- Mixed
Appetite- Decreased
Sleep- Adequate
Bowel and bladder movements- Regular
Addictions- Alcohol consumption since 10 to 12 yrs. Consumes 180 ml almost everyday
Tobacco chewing since 10 to 12 yrs
Allergic history:
No history of known allergies
Family history:
No significant family history
No family history of Hypertension, Diabetes, Asthma, TB, Epilepsy
General Physical Examination:
Patient is conscious, coherent, cooperative
well oriented to time, place, and person
well nourished and moderately built
Pallor- Absent
Icterus- Absent
Cyanosis- Absent
Clubbing- Absent
Lymphadenopathy- Absent
Edema- Absent
Vitals:
Temperature- Afebrile
Pulse rate- 99bpm
Respiratory rate- 15cpm
Blood pressure- 140/90 mm/Hg
SPO2- 98%
GRBS- 126 mg%
Systemic Examination:
Cardiovascular System:
S1 and S2 sounds are heard
No abnormal murmers
Respiratory System:
Bilateral air entry present
Trachea is central
Normal vesicular breath sounds are heard
No adventitious sounds are heard
Central Nervous System:
No focal neurological deficits
Abdominal Examination:
Inspection:
On inspection, abdomen is scaphoid, the umbilicus is inverted.
No visible peristalsis, pulsations, engorged veins, and no hernial sites.
Negative cullen's sign, grey turner's sign, fox's sign
Palpation:
Inspectory findings are confirmed.
There is tenderness, guarding and rigidity.
Percussion:
Tympanic sounds are heard
Auscultation:
Bowel sounds are heard
No bruits
Investigations:
CBP-
Hb- 11
PCV- 22.8
MIV- 65.7
MCH- 21.0
MCHC- 32.0
Platelet- 3.5 L
RBC count- 3.47
Reticulocyte count- 0.7%
Complete Urine Examination:
Albumin- Nil
Specific gravity- 1.010
Pus cells- Nil
Epithelial cells- Nil
RBCs- Nil
Crystals- Nil
Casts- Nil
Liver Function Tests:
AST- 12
ALT- 16
ALP- 339
TP- 6.3
Albumin- 3.0
A/G- 0.78
Serum Electrolytes:
Sodium- 140 mEq/L
Potassium- 3.5 mEq/L
Chloride- 96 mmol/L
Serum creatinine - 1.0mg/dl
Renal Function Tests:
Urea- 62 mg/dl
Creatinine- 1.0 mg/dl
Uric acid- 6.7 mg/dl
Serum Amylase
Serum Lipase
ECG
USG
COLOUR DOPPLER 2D ECHO
PSYCHIATRIC REFERRAL:
He was sent for Psychiatric referral to evaluate for alcohol dependence
He is also diagnosed with alcohol dependence syndrome
PROVISIONAL DIAGNOSIS:
Acute Pancreatitis due to alcohol dependence
Treatment:
- Intravenous fluids -NS, RL, DNS
- Inj. PANTOP IV/OD
- Inj. ZOFER IV/OD
- Inj. THIAMINE 1 amp in 100ml/NS/IV/OD
- Inj. TRAMADOL 1 amp in 100ml/NS/IV/SOS
- BP/ PR/ Temperature charting
- Strict I/O monitoring
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