50M with pain abdomen and SOB

Hello all this is G Jagadeesh,a fifth semester student 

This elog depicts the patient -centered approach to learning . This is an online E log book recorded to discuss and comprehend our patients de-identified health data shared , after taking his /her /guardians signed informed consent . This elog also reflects patients centered learning portfolio.

CASE

A 50 year old male , maths lecturer by occupation, resident of nalgonda came to OPD with chief complaints of 

1. Abdominal pain since 4days.

2. Shortness of breath since 3days. 

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 10years ago , then he developed gastric problem whenever he takes alcohol for which he is using omeprazole and rabiprazole . He vomits wantedly the next day morning he took alcohol every time. 4days back he developed upper abdominal pain which was gradual in onset and progressive with abdominal distension .

 HISTORY OF PAST ILLNESS

Known case of Hypertension since 4years 

Not a known case of DM, asthma, TB, Epilepsy.

PERSONAL HISTORY

Marital status : Married

Occupation : Maths lecturer

Diet : Mixed

Appetite: Normal

Bowels : Regular

Micturition : Normal

He has no known allergies

Addictions 

Alcohol : Occasionally since 20 years(90ml/180 ml/day)

But he is taking alcohol frequently since 15 to 20 days.

Tobacco : Smoking since 20years (8/day)

TREATMENT HISTORY

He is taking Tab. Angiosart(telmisartan+ hydrochlorothiazide) for HTN since 4years.

Tab. Omeprazole and Tab. Rabiprazole for gastric problem since 10years.

FAMILY HISTORY

His brother also had gastric problem since 10 years.

GENERAL EXAMINATION

Patient is conscious, coherent , cooperative and examined in a well lit room. 

Moderately built and nourished.

VITALS 

Pulse Rate: 101/min

Blood pressure: 130/90 mmHg

Respiratory rate: 18/ min

Temperature : 98.6°F

Spo2 : 99%

GRBS : 155mg/dl

PHYSICAL EXAMINATION

Pallor : present 

Icterus : absent

Cyanosis : absent

Clubbing of fingers and toes : absent 

Lymphadenopathy : absent

Edema : absent

Malnutrition : absent

Dehydration : absent

SYSTEMIC EXAMINATION

CARDIOVASCULAR SYSTEM

S1 and S2 are heard 

No thrills

No murmurs

RESPIRATORY SYSTEM

Dyspnea : present

No wheezing

Trachea : central

Vesicular breath sounds : Normal

PER ABDOMEN

Shape : Distended


Tenderness : diffuse type

No palpable mass

Hernial orifices : Normal

No free fluid

No bruits

Bowel sounds : present

 CENTRAL NERVOUS SYSTEM

Conscious

Speech : Normal

No signs of meningeal irritation

Cranial nerves :  intact

Motor system : Normal

Sensory system : Normal

Reflexes : Normal

INVESTIGATIONS

18/7/22

ECG


HEMOGRAM


COMPLETE URINE EXAMINATION


BLOOD GROUPING


19/7/22

RENAL FUNCTION TEST(RFT)


LIVER FUNCTION TEST (LFT)


SERUM LIPASE 


SERUM AMYLASE


20/7/22

ULTRASOUND


21/7/22


PROVISIONAL DIAGNOSIS

Acute pancreatitis secondary to alcohol.

TREATMENT

OVF(RL & NS) 150ml/hr

INJ.PANTOP 40mg/IV/OD

INJ.ZOFER 4mg/IV/SOS

INJ.TRAMADOL 1amp in 100ml IV/BD

INJ.THIAMINE 200mg in 100ml NS

NBM till further orders

Ryle's tube aspiration 4the hourly

Abdominal girth measurement daily

Monitor vitals 4th hourly

Strict I/O charting


 

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