40M pain abdomen

Hello all this is G Jagadeesh,a eight semester student.This E Log depicts the patient centered approach to learning 

This is 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 patients 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 comment box is welcome."

" 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 diagnosis and treatment plan "

40 yr old male patient who is daily wage labourer by occupation came to OPD with

Chief complaint

of pain abdomen since 5 days associated with fever since 2 days 

HOPI

Patient was apparently asymptomatic 5 days ago then he developed pain which is insidious in onset and gradually progressive which is diffuse , squeezing type and radiating to back .

Pain is relieved on medication .

No C/O of vomitings , loose stools , burning micturition ,cough,cold , chest pain , SOB 

.

Past history

N/K/C/O TB , hypertension, diabetes, Asthma, epilepsy , CAD, thyroid disorders .

Personal hisrory

Diet - mixed 

Appetite- normal

Bowel and bladder -regular

Sleep - adequate

Addictions - regular alcohol intake of 250 ml per day since 20 yrs .

No food allergies and drug allergies

General examination

Pallor - yes 

Edema -absent 

Clubbing - absent 

Lymphadenopathy - absent 

Icterus - absent 

Cyanosis absent

 Vitals

Temperature - 100.1F

BP-85/60

Spo2- 98%

RR-20pm

PR- 100/min

Systemic examination 

Per abdomen examination

Patient exposed from nipple to mid thigh and examined in supine position 

INSPECTION: 

• Shape:Distended flanks full 

• Umbilicus:inverted,vertically drawn down

• Skin over the abdomen is shiny

• No visible peristalsis,

  
  

• Palpation:

  On superficial Palpation 

  • All inspectory findings are confirmed 

  • Tenderness+

  • ,diffuse all quadrants

  • No Rebound tenderness 

• No guarding,rigidity

  Percussion

  
  

  Shifting dullness  absent 

  fluid thrill absent 

  Liver span-12cm

  Percussion of spleen : dullness in 9th inter coastal space of anterior axillary line 

  Auscultation 

  Bowel sounds+

  No arterial bruit,

  
  

  RESPIRATORY SYSTEM 

  Inspection 

  • Shape of chest:Bilaterally symmetrical,Elliptical in shape

  • No visible chest deformities

  • Abdomino thoracic respiration,No irregular respiration

  • No tracheal shift

  • No dropping of shoulders, on both sides,no sinuses,scars,engorged veins

  
  

  Palpation:inspectory findings confirmed by Palpation 

  • Chest movements -normal

Percussion:

Resonant note heard over all areas 

Auscultation: 

Norma vesicular breath sounds

, breath sounds normal 

Cardiovascular system:

Inspection:precordium normal,apex beat :5th ICS half inch medial to mid clavicular line

Palpation:inspectory findings confirmed,No thrills or parasternal heave

Auscultation: S1S2+,no murmurs

CNS:

 - 

patient is arousable 

No signs of meningitis 

cranial nerves intact,motor and sensory examination normal

No cerebellar or meningeal signs

Reflexes:

Knee         3+.     3+

Reflexes          Rt.  Lt 

Biceps               3+.   3+

Triceps              3+.    3+

Supinator          2+.    2+

Knee                  3+.     3+

              Right.        Left 

UL.        2/5.        3/5

LL.          2/5.      3/5

provisional diagnosis 

 Acute pancreatitis ( non necrotizing type) peripancreatic fluid collection.

Investigations:

Treatment

1 .IV fluids 125ml/hr 

2.injec.zoffer 4 mg IV

3.inj Tramadol 1 ampoul in 100ml NS

4.inj piptaz 4 to 5 mg 

5. Inj pan 40 mg IV

6.inj neomol 1gm IV