A 27 year old male patient came with abdominal pain

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Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

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 a diagnosis and treatment plan.

Following is the view of my case...

CASE:

27 year old male patient who is a resident of vemanapalli and electrician by occupation came to OPD with chief complaints of abdominal pain since 3 months(November 2021

History of presenting illness:

Patient was apparently asymptomatic 4 months back then he had vomitings which were non projectile ,bilious,green in colour, contents were food material he had ate,vomitings come immediately after eating food

Then he went to a government hospital in Vijayawada and symptomatic treatment is given but vomitings are not subsided

He went to a another private hospital in Vijayawada there they inserted a tube through his mouth and removed green coloured liquid which was almost a litre in amount,from then the vomitings are subsided and they treated him as pancreatitis case

Then he developed abdominal pain in the middle of November 2021 which was sudden in onset, intermittent in nature , squeezing type of pain,which was increased on taking the food very severly persists for 2 to 3 hours after taking medication it relieves and pain is referred to back and it is more around the left hypochondrium and epigastrium and sometimes pain gets relieved by resting in between the meal timings 

Patient was referred to a Contrast enhanced CT scan of abdomen in the same private hospital,after taking the contrast he had severe vomiting once and from the CT results patient was declared as having pancreatitis with pseudocyst

Patient was discharged and he had symptom free interval for 7 to 10 days and he again developed abdominal pain which is intermittent and relieved by taking medication

He had covid infection in January 2022 and he took treatment in home isolation 

He reffered to our hospital and he came to our hospital on 7-2-2022

Past History:

Not a known case of Diabetes, hypertension,asthma, tuberculosis,CHD,thyroid disorders

Family History:

Not significant

Personal History:

Diet-mixed

▪ Appetite-increased

▪Bowel movements-Regular

▪Bladder movements-Regular

▪Sleep -inadequate

▪Habits- he was alcoholic and not a smoker from last 4 years

daily he drinks alcohol of 500 to 600 ml till October ending 

GENERAL EXAMINATION

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

and person, moderately built and moderately nourished

- Pallor- absent

-Icterus-absent

-Cyanosis-absent

-Clubbing-absent

-Lymphadenopathy-absent

-Edema-absent

ON EXAMINATION : 

*Patient is conscious, coherent, cooperative.

* Pallor , Icterus,Clubbing, Cyanosis , Koilonychia, Edema and lymphadenopathy are absent

VITALS 

Temp- Afebrile 

Bp-100/80 mm hg

Pr- 84bpm

Rr-16cpm

Spo2- 99% on RA

Grbs : 102

SYSTEMIC EXAMINATION : 

CVS -S1 S2 +; No Murmurs.

PER ABDOMEN - 

1)Tenderness present in epigastric region and left hypochondrium 

2)Rigidity present in the epigastric region and left hypochondrium 

3)No gaurding 

4)Bowel sounds present 

CNS:- NAD 

INVESTIGATIONS :- 

#HEMOGRAM -

HB 10.5 GM/DL 

TLC #10,500 

N/L/E/M/B. #135/20/#40/05/00

PCV #32.5 

MCV # 82.7 

MCHC 32.6 

RBC. #3.93 

PLT. 5.5 

CUE :- 

ALBUMIN. NIL 

BILE SALTS AND PIGMENTS NIL

PUS CELLS NIL 

LFT :- 

TB 0.48 MG/DL

DB 0.17 MG/DL

SGOT 13 IU/L 

SGPT. 14 IU/L 

ALP. # 291 IU/L

Tp. # 5.9 gm/dl 

albumin. #2.92 gm/dl 

A/G RATIO. 0.98 

SERUM AMYLASE. 292 

SEROLGY. NEGATIVE 

CRP POSITIVE 2.4 MG/DL

USG:

CECT:

PROVISIONAL DIAGNOSIS:-

CHRONIC PANCREATITIS WITH PSEUDOCYST .

TREATMENT:-

1) IVF NS /RL @75 ml / hr 

2) Inj Tramadol 100 ml IV /TID 

3) Inj pantop 40 mg iv/ OD 

4 ) Inj zofer 4 mg iv/sos.

5)Syrup. Cremaffin plus 15/ml/po.

Progress Notes:

Patient was sent for a gastroenterologist opinion and asked for endoscopy to be done

But endoscopy didn't done and advised for a surgical removal of pseudocyst