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 i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan
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 came to OPD with
C/O abdominal pain in the epigastric region since 10 days which is intermittent aggrevate on palpation and releived on medication and got check at rmp clinci then gave some medication and on fluids and releived then again on the same night he got another episode of similar type of pain and get admitted in suryapet and underwent investigations and diagnosed as pancreatitis and liver cirrhosis and underwent treatment for 2 days and got discharged
There are 2 episodes of vomiting which is non projectile and non blood stained and content is food particles.
Complaints of cold since 6 days and cough since 5 days which is dry type at beginning and came with expectorant after 3 days and there is shortness of breath which is on rest
Past history:
7 years ago they went to hospital with complaints of pain in the loin region and decreased Urine output and went to hospital and diagnosed as renal calculi and taken medication and got relieved.
3 years ago there pain in the right hand and tingling numbness along the right hand and went to hospital and diagnosed as cervical C3 C4 disc compression and underwent ayurvedic treatment for 15 days and got relieved.
Personal history:
Diet mixed
Appetite normal
Sleep adequate
Bowel and bladder regular
He is alcoholic since 15 years daily , 180ml/ day and chewing of tobacco since 15 years ,1 packet /day. Last alcohol on 5th Oct (binge alcohol for 1 week)
Not a k/c/o HTN, DM, ASTHAMA, TB, EPILEPSY, CAD ,CVA.
General examination
Patient is c/c/c
No pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.
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
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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