40 Y/M with abdominal pain and vomitings

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.

3- March -2022

40year old male who works as a field assistant who is chronic alcoholic came to casualty with complaints of abdominal pain since one day & vomitings (10-15 episodes) since one day.

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 1 day back , since 3 days there h/o binge alcohol consumption (360ml whisky) after which since 1 day he developed pain abdomen which was squeezing type predominantly in epigastric region diffuse type associated with nausea & vomiting 10 to 15 episodes/day. Whenever he consumes water or food he has vomitings - nonbilious, non projectile, water or food as content.

No h/o loose stools or constipation

No h/o fever ,shortness of breath, cough

PAST HISTORY

H/o pancreatitis 3 years ago

He is a k/c/o diabetes mellitus since 15 yrs, since 1 yr using HAI 10U in the morning & 5U in the night , before which he was on oral hypoglycemic agents

He is a k/c/o hypertension since 10 yrs using T. AMLODIPINE 5mg OD

GENERAL EXAMINATION

Pt is c/c/c

No Pallor, Icterus, Edema, Clubbing, Lymphadenopathy.

Vitals :

Temp: 98.4 f

HR: 100 bpm

RR : 18cpm

BP : 160/80 mm hg

Spo2: 99 @ RA

GRBS : 297 mg/dl

SYSTEMIC EXAMINATION :

CVS : S1 S2 + .

RS : BAE + NVBS +

PA: Diffuse tenderness present, more in left hypochondriac region, epigastric region & left iliac fossa

CNS : NAD

PROVISIONAL DIAGNOSIS : Acute Pancreatitis

INVESTIGATION

2D ECHO

USG

SEROLOGY

ECG

TREATMENT :

IVF : NS , RL @ 100ml/hr

INJ. ZOFER 4mg IV /BD

INJ.PANTOP 40mg IV/OD

INJ. TRAMADOL 1amp in 100ml NS IV/BD

INJ. PIPTAZ 2.25gm IV /QID

TAB. AMLONG 10mg PO/OD

GRBS monitoring

INJ. HUMAN ACTRAPID according to sugars

Inform SOS

Comments

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