27 YEAR MALE PATIENT WITH ? PAIN ABDOMEN
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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 in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan
27 year old male patient resident of nalgonda auto driver by occupation came with complaints of
pain abdomen since 3 days
1 episode of Vomitings yesterday
HOPI:-Patient was apparently asymptomatic 3days back then he developed pain in the abdomen which was insidious in onset, gradually progressive,dragging type of pain radiating to the back,aggrevated on walking and relieved on bending forwards.
H/O 1 episode of Vomitings,non bilious,non blood stained with food as contents.
No H/O fever,cough,breathlessness.
No H/O chest pain,palpitations,orthopnea
No H/O burning micturition
PAST HISTORY:
Not a known case of DM,HTN,ASTHMA, TB, EPILEPSY,CVA and CAD.
H/O similar complaints in the past in aug 2023 and was diagnosed with acute necrotising pancreatitis and was treated outside.
PERSONAL HISTORY:
Diet:Mixed
Sleep:adequate
Appetite:Normal
Bowel and bladder movements:Regular
Addictions:patient was chronic alcoholic since 2016,started taking 2-3 beers in a week and later shifted to 3 quarters per day of whisky for 4years and later went to hospital with similar complaints in 2020 and undergone pancreatic stenting which was later removed after 15days of placing it.Stopped drinking alcohol for approximately 2 years and later again started drinking alcohol due to peer pressure and stress,had similar episodes for 3times and was treated for the same.
Non smoker
FAMILY HISTORY:Not significant
General examination:
Patient is conscious, coherent, cooperative well oriented to time,place and person.
No pallor, Icterus, cyanosis, clubbing, lymphadenopathy and edema.
VITALS:
TEMP:- 98.6°F
BP :- 150/80 mm hg
PR:- 80 bpm
RR:- 19 cpm
GRBS:- 210 mg/dl
SPO2:- 98% AT RA
SYSTEMIC EXAMINATION:-
PER ABDOMEN:-
Inspection:
Shape - distended
Flanks-full
Umbilicus - inverted
All quadrants moves equally with respiration
No engorged veins, visible pulsations,scars,sinuses
Palpation:
All inspectory findings are confirmed
No local rise of temperature
Abdomen is soft and non tender
spleen and liver -not palpable
No other palpable masses
Hernial orifice are free
Percussion:
Shifting dullness absent
Auscultation:
Bowel sounds heard
CVS EXAMINATION:-
Jvp not raised
Inspection:
Shape of chest - elliptical
No visible pulsations
No engorged veins and scars
Apical impulse not visible
Palpation:
Apex beat present over the left 5th intercostal space 1cm medial to midclavicular line
No parasternal heave
No precordial thrill
No dilated veins
Auscultation:
S1 S2 heard ,No murmurs
RESPIRATORY SYSTEM:- BAE+,Normal vesicular breath sounds heard.
CNS EXAMINATION:-
No focal neurological deficits
INVESTIGATIONS:-
SERUM LIPASE ON 6/12/23:-
SERUM AMYLASE ON 6/12/23:-
HAEMOGRAM ON 7/12/23
CUE ON 7/12/23
RBS ON 7/12/23
RFT ON 7/12/23
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