4o yr old patient with abdominal pain




40M WITH ABDOMINALPAIN


Hello all , I E. Tejaswi of eighth semester student.This E Log depicts the patient centered approach to learning

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.

40 yr old male patient who is daily wage labourer by occupation came to OPD with
Chief complaint
of pain abdomen since 5 days associated with fever since 2 days 

HOPI
Patient was apparently asymptomatic 5 days ago then he developed pain which is insidious in onset and gradually progressive which is diffuse , squeezing type and radiating to back .
Pain is relieved on medication .
No C/O of vomitings , loose stools , burning micturition ,cough,cold , chest pain , SOB 

Past history:-
N/K/C/O TB , hypertension, diabetes, Asthma, epilepsy , CAD, thyroid disorders .

Personal hisrory:-
Diet - mixed 
Appetite- normal
Bowel and bladder -regular
Sleep - adequate
Addictions - regular alcohol intake of 250 ml per day since 20 yrs .
No food allergies and drug allergies

General examination:-
Pallor - yes 
Edema -absent 
Clubbing - absent 
Lymphadenopathy - absent 
Icterus - absent 
Cyanosis absent

 Vitals:-
Temperature - 100.1F
BP-85/60
Spo2- 98%
RR-20pm
PR- 100/min

Systemic examination:-
Per abdomen examination

Patient exposed from nipple to mid thigh and examined in supine position 

INSPECTION: 

  • Shape:Distended flanks full 

  • Umbilicus:inverted,vertically drawn down

  • Skin over the abdomen is shiny

  • No visible peristalsis,

  • Palpation:

    On superficial Palpation 

    • All inspectory findings are confirmed 

    • Tenderness+

    • ,diffuse all quadrants

    • No Rebound tenderness 

  • No guarding,rigidity

    Percussion

    Shifting dullness  absent 

    fluid thrill absent 

    Liver span-12cm

    Percussion of spleen : dullness in 9th inter coastal space of anterior axillary line 

    Auscultation 

    Bowel sounds+

    No arterial bruit,

    RESPIRATORY SYSTEM 

    Inspection 

    • Shape of chest:Bilaterally symmetrical,Elliptical in shape

    • No visible chest deformities

    • Abdomino thoracic respiration,No irregular respiration

    • No tracheal shift

    • No dropping of shoulders, on both sides,no sinuses,scars,engorged veins

    Palpation:inspectory findings confirmed by Palpation 

    • Chest movements -normal

Percussion:

Resonant note heard over all areas 

Auscultation: 

Norma vesicular breath sounds

, breath sounds normal 

Cardiovascular system:

Inspection:precordium normal,apex beat :5th ICS half inch medial to mid clavicular line

Palpation:inspectory findings confirmed,No thrills or parasternal heave

Auscultation: S1S2+,no murmurs

CNS:

patient is arousable 

No signs of meningitis 

cranial nerves intact,motor and sensory examination normal

No cerebellar or meningeal signs

Reflexes:

Reflexes          Rt.      Lt 
Knee                3+.      3+
Biceps               3+.    3+
Triceps              3+.    3+
Supinator          2+.    2+
Knee                  3+.     3+

              Right.        Left 
UL.        2/5.           3/5
LL.          2/5.         3/5

provisional diagnosis :-
 Acute pancreatitis ( non necrotizing type) peripancreatic fluid collection.

Investigations:







Treatment:-
1 .IV fluids 125ml/hr 
2.injec.zoffer 4 mg IV
3.inj Tramadol 1 ampoul in 100ml NS
4.inj piptaz 4 to 5 mg 
5. Inj pan 40 mg IV
6.inj neomol 1gm IV


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