A 32 yr old male...
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I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis to develop my compentency in reading and comphrending clinical data including history , clinical finding , investigation and come up with diagnosis and treatment plan....
A 32yr old male electrician by occupation came with the complaints of pain in epigastric region since 20days, SOB since 2days and acute pancreatitis diagnosed from other hospital.
Vomitings 5 days ago, Cold since 6 days, Cough since 5 days.
**HISTORY OF PRESENT ILLNESS:-**
Patient was apparently asymptomatic 20 days ago and he had pain in epigastric region which is aggravated on palpation and relieved for some time by the medication and injection given by the RMP doctor, then he had the similar type of the pain in the mid night then he admitted in Suryapet hospital where he diagnosed as Acute pancreatitis and liver enlargement underwent treatment for nearly 4 days and he reffered to our hospital since he was having pleural effusion confirmed by chest x-ray.
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.
**HISTORY OF PAST ILLNESS:-**
Lower left rib air line fracture.
Renal calculi 5yrs ago which is relieved by medications.
UTI with fever 6months ago.
Not k/c/o DM, HTN, Asthma, TB, epilepsy, COPD, CVD.
**PERSONAL HISTORY:-**
DIET: mixed
APPETITE: reduced
SLEEP: adequate
BOWEL MOVEMENTS: constipated
BLADDER MOVEMENTS: Normal
ADDICTIONS:
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.)
ALLERGY: to fish
**GENERAL EXAMINATION:-**
Patient is c/c/c. Oriented to time place and person.
Has mild pallor,
No icterus, clubbing, cyanosis, lymphadenopathy, edema.
Has moderate bulid and nourishment.
Patient is afebrile
Vitals:
BP:140/70mmHg
PR:78bpm
RR:23cpm
GRBS:201
SpO2:89%
**SYSTEMIC EXAMINATION:-**
P/A:-
Inspection:
shape: obese and symmetrical.
Falnks:free.
Skin over abdomen: normal
Umbilicus:normal.
There is a swelling in epigastric region
No visible engorged veins, pulsations, peristaltis, scars or sinuses.
Palpation:
girth - 113 cm
No local rise of temperature.
Tenderness in all quadrants.
Liver is non tender and non pulsatile, smooth surface, hard in consistency, Sharpe edge.
Spleen is non palpable.
Percussion:
No fulid thrills
No shifting dullness
Auscultation:
Bowel sounds normals
No bruits.
CVS:
No thrills or murmurs
S1,S2 heard.
RS:
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.
**Investigation:-**
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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