MEDCINE FINAL PRATICAL (SHORT CASE)

22yr old with c/o pain abdomen

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box 



Hall ticket no. 1701006156




CONSENT : An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references. 

 DOA: 7/6/2022

A 22yr old male pt. painter by occupation resident of nalgonda came with 

Chief Complaints:

Pain abdomen since 4 days.

HOPI:

Pt. Has started consuming alcohol 4 yrs back due to peer pressure , intially taking one peg per day which has increased to 90ml morning and evening i. e twice daily. He has stopped consuming alcohol 3 months back as advised by the doctor.

Pt. Has history of smoking since 2 yrs . He has been smoking beedies 5 per day till date.

Pt was apparently asymptomatic 3 months back then he developed abdominal pain which was dragging in character for which he was admitted in near by hospital in nalgonda . He was diagnosed with acute pancreatitis and was treated inadequately and was advised to stop consumption of alcohol. 

Since then pt has stopped consuming alcohol and has been experiencing alcohol withdrawal symptoms like getting angry , agitation , irritability , craving to consume alcohol, tremors . Pt had consumed alcohol 4 days back due to family problems.

In veiw of this symptoms pt.has been brought to psychiatry OPD for deaddiction. He was referred to medicine OPD in veiw of pain abdomen.

Pain was , insidious in onset , started after consuming of alcohol in epigastrium and left hypochondrium which was relieved on bending forward and lying down , aggrevated on eating food and standing straight.

No h/o fever , nausea , vomiting.

Past history:

H/o similar complaint in past 3 months back.

No other co morbid conditions

No h/o previous medical surgical history. 

Family History 


Not significant 



Diet : mixed 

Appetite : normal

Bowel bladder: regular 

Sleep: inadequate 

GENERAL EXAMINATION 

Pt was concious coherent and cooperative

Thin built and moderately nourished



ABDOMEN 



No icterus,cyanosis , clubbing,lymphadenopathy, edema


Vitals

Temperature- afebrile

Pulse rate-94bpm

Blood pressure-120/80mmHg

Respiratory rate- 16cpm

Systemic examination:

Abdominal examinations: 

Inspection:

Okay Shape of the abdomen- flat

Umbilicus is central

No visible  scars,pulsations, peristalsis, engorged veins

Palpation:

All the inspectory findings are confirmed.

Tenderness present over the epigastrium region

No organomegaly



Percussion

No free fluid

Ascultation:

Bowel sounds heard


Other systems: 

Respiratory:

 b/l air entry present , no added breath sound

CVS : 

S1 S2 heard , no added murmurs 

CNS : 

Higher function intact 

No motory and sensory deficit.

Cranial nerves normal .

Investigations

Complete blood picture

Complete urine examination

RFT


USG abdomen


Serum amylase 

Serum lipase

Diagnosis: 
acute pancreatitis.


TREATMENT 

Nil per oral
IV fluids Ringer lactate 
,Normal saline 100 ml per hour
Inj. Tramadol100mg in 100ml NS IV BD
Inj.pantop 40 mg IV OD
Inj. Optineuron 1 ampoule in 100ml NS IV OD

Psychiatry medication

Tab . Lorazepam 2mg BD
Tab . Benzothiamine100mg OD


12/06/22 FOLLOW UP

VITALS

pulse rate: 92 bpm
BP: 110/70mm of hg
Temp: afebrile 
CVS: S1S2 heard
CNS: NAD
Lungs: BAE+

TREATMENT 

IV Fluids RL/NS at the rate 75/min
Allow soft diet orally 
Continue same medications as above






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