65/M C/O PAIN ABDOMEN,? ALCOHOLIC GASTRITIS
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I've 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 a diagnosis and treatment plan.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.
Patient came to the casuality with chief complaints of abdominal pain since 5 days.
HOPI:
Patient was apparently asymptomatic 5 days back then he developed pain in the abdomen more in the epigastric region , burning type , with no radiation ,Aggravated with food intake and relieved on taking medication.
Had similar complaints 1 year back - went to the hospital with abdominal pain and was diagnosed as jaundice for which he was treated.
DAILY ROUTINE:
He wakes up at 6 am and gets freshened up. Drinks tea at 7 am followed by breakfast ( rice with curry) at 9 am. Leaves home for work( works as Shepard) at 9am and works till 7 pm. In between eats lunch at 2 pm and drinks tea at 5 pm. Eats dinner at 8 pm and sleeps at 9 pm.
PAST HISTORY:
Not a k/c/o Dm, Htn, asthma, Epilepsy, thyroid disorders, cad, cvs
Had similar complaints 1 year back - went to the hospital with abdominal pain and was diagnosed as jaundice for which he was treated.
SURGICAL HISTORY:
Operated for B/l hydrocele and hernia 20 years back.
PERSONAL HISTORY:
Diet: Mixed
Appetite: decreased
Sleep: Adequate
Bowel and bladder movements: Regular
Addictions:
Alcohol consumption since 45 years every day and occasionally since 10 years.
Smoking since 40 years stopped 1 year back.
GENERAL EXAMINATION:
Patient is conscious,coherent,cooperative
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema.
Temp:97.8F
Bp:120/80 mm Hg
Rr:18 cpm
Pr:81 bpm
SYSTEMIC EXAMINATION:
PER ABDOMEN
Inspection:
- Abdomen is obese
- Umbilicus is central
- All quadrants move equally with respiration.
- No scars, sinuses, engorged veins
Palpation:
- soft
- Tenderness present over left hypochondrium, epigastric region.
- No local rise in temperature
- All the inspectory findings are confirmed
Percussion:
Resonant
Auscultation:
Bowel sounds heard.
CNS: nfnd
CVS: S1 S2 heard,No murmurs
RS: blae+ , NVBS heard
Investigations:
24/6/23
Hemogram:
Hb-11.9 g/dl
Tlc-6500
Pcv-35.1
RBC -4million/mm³
Platelet count-1.5 lakhs
Blood urea- 17 mg/dl
Liver function test:
Serum Creatinine -1.0 mg/dl
Serum Amylase-29 Iu/L
SERUM LIPASE-10 Iu/L
Complete Urine Examination:
Random Blood sugar- 131 mg/dl
25/6/23
Fasting blood sugar- 104 mg/dl
Prothrombin time- 17 seconds
Aptt- 35 seconds
Inr-1.25
GLYCATED HEMOGLOBIN - 6.5
LDH- 249
Peripheral Smear-
Hemogram
Liver function test:
28/6/23:
29/6/23:
DIAGNOSIS:
Pain abdomen secondary to ? Alcoholic gastritis? Acute pancreatitis
TREATMENT:
- Nbm till further orders
-Iv fluids: Ns, RL, DNS @ 100ml/hr
- inj. Thaimine 200mg iv/bd
- inj. Tramadol 1 amp in 100ml ns/iv/ sos
- inj. Pan 40 mg/iv/od
- inj zofer 4 mg iv/sos
- inj. Buscopan im/sos
posted by 54 Harika Kathumandi @ June 28, 2023
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