36YEAR MALE WITH PAIN ABDOMEN
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I have 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 coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.
MED CASE:-
A 36-year-old male with pain abdomen
CHIEF COMPLAINTS:-
The patient came to casualty with complaints of
Pain in abdomen for 2 days
2 episodes of vomiting in 2 days
HISTORY OF PRESENTING ILLNESS:-
The patient was apparently asymptomatic 2 days back and developed 1 episode of fever; in the evening which was not associated with chills and rigor and was relieved on medication.
The patient developed pain abdomen 1 day which was squeezing type in nature, insidious in onset, and intermittent; pain radiating to the upper back and left lumbar region; relief in the right lateral position.
H/O 2 episodes of vomitings ; bilious in nature
Scanty non-foul-smelling
H/o anorexia since yesterday
H/o similar complaints in the past of pain abdomen
(Treated locally with some unknown medication) for liver pathology?
PERSONAL HISTORY:-
My appetite lost for 2 days
Sleep adequate
Bowel and bladder regular
Alcohol since 10 yrs ( occasionally in parties)
Around 90 ml to 180 ml of whisky
Smoking occasionally for 10 years (1-2) cigarettes
PAST HISTORY:-
NOT A KNOWN CASE OF DM ; HTN ; TB; CAD; ASTHMA ; CKD; CVA ; EPILEPSY
No h/o any previous surgeries in the past
ALLERGIC HISTORY:-
No kind of allergies to any kind of food or drugs
TREATMENT HISTORY:-
No significant treatment.
GENERAL EXAMINATION:-
THE PATIENT IS CONSCIOUS COHERENT AND CO COOPERATIVE
NO PALLOR ; ICTERUS; CLUBBING; CYANOSIS; LYMPHADENOPATHY; ODEMA
TEMPERATURE:- AFEBRILE
PR:81bpm
BP:120/80mmhg
RR:18cpm
SYSTEMIC EXAMINATION:-
P/A:-
inspection:- abdomen is obese
Umbilicus is central and inverted
All quadrants of the Abdomen move accordingly with respiration.
No visible masses ; pulsations
No scars on sinuses; no engorged veins
Palpation:- no local rise of temperature
Tenderness in right lumber right hypochondrium
No rigidity
Guarding present
Auscultation:- Bowel sounds sluggish
CVS:S1 S2+,NO MURMURS
CNS: NAD
RS:BAE+ ; NVBS
INVESTIGATIONS:-
22/8/23 :-
RBS - 128 mg/dl
Blood group:- A +
BT - 2min
CT - 4 min 30 sec
PT 17 sec
INR -1.2
CBP:-
Hb:- 13.8 gm/dl
TLC :- 13,400 cells N-85/L-10/E-2/M-3/B-0
PLT - 2.50 lakhs
CUE:-
Alb- Trace
Sugars - nil
Pus cells - 3-4 cells
epi:- 2-3 cells
LFT:-
Total bilirubin -1.68 mg/dl
Direct - o. 40 mg/dl
SCOT (AST):- 32 IU/L
SGPT [ALT] - 19 IU/L
ALKALINE PHOSPHATE:- 120 IU/L
TOTAL PROTEINS:- 5.9 gm/dl
RFT:-
Serum creatinine:- 1.1 mg/dl
Serum Na :- 136 mEq/L
Serum K :- 3.5 mEq/L
Serum cl :- 103 mEq/L
23/08/23:-
S.Amylase:- 104IU/L
S.lipase:- 64 IU/L
24/08/23:-
Hb:- 12.4 gm/dl
TLC:- 11,400
PCV:- 35.7
MCV:- 86
MCH:- 29.9
MCHC:- 34.7
PLt:- 2.04
B.urea - 29 mg/dl
S.creat - 1.0 mg/dl
Na-140mEq/L
K - 4.1 mEq/L
Cl- 102 mEq/L
25/8/23:-
Hb:- 12.2
TLC:- 9,300
PCV:- 36.4
MCV:- 88.0
MCH:- 29.6
MCHC:- 33.6
PLT:- 2.27
DIAGNOSIS:-
ACUTE INTERSTITIAL PANCREATITIS (RESOLVING)
COURSE IN HOSPITAL:-
The patient presented to the casualty on 21/8/23 with complaints of Pain abdomen (right hypochondrium) from 20/8/23
2 episodes of vomiting from 20/8/23
Then was admitted under general surgery for further evaluation and was investigated further for the evaluation of pain abdomen and causes of distension. The patient has not passed Flatus and feces for the past 2 days so the below investigations are ordered and the emus further evaluated.
Then an emergency ultrasound was done to rule out gallstones but the report was given as normal.
Then the patient was taken to the x-ray and a chest x-ray was done to rule out gas under the diaphragm and any hollow viscus perforation but the x-ray was normal. An erect abdomen was done which showed some dilated loops but were not significant for any obstruction.
And was started conservatively.
Then patient was investigated with amylase and lipase levels which were found to be raised ( 104 IU/L ) but the levels of lipase were normal and in the suspicion of pancreatitis CT was advised and it showed
IMPRESSION:
- ACUTE EDEMATOUS INTERSTITIAL PANCREATITIS CONFINED TO THE HEAD AND UNCINATE
PROCESS
⁃ NO CALCIFICATIONS
⁃ MILD ASCITES
⁃ NO VASCULAR COMPLICATIONS
⁃ MILD RIGHT PLEURAL EFFUSION
⁃ MODIFIED CT ST SCORE 4/10.
But then was transferred to the Gen medicine for the further management of pancreatitis.
THE PATIENT WAS GIVEN SYMPTOMATIC TREATMENT AND WAS NBM FOR 3 DAYS AND THEN STARTED ON A SOFT DIET.
And now PATIENT HAS NO COMPLAINT OF THE PAIN ABDOMEN.
THE PATIENT IS HEMODYNAMICALLY STABLE AND ADVISED FOR DISCHARGE.
WHEN THE PATIENT WAS ADMITTED THE BISAP SCORE WAS AROUND 2 WHICH MEANS THE MORTALITY WAS AROUND 3.6 PERCENT AND AT THE TIME OF DISCHARGE THE BISAP SCORE IS 0 WHICH MEANS THE MORTALITY IS 0.1 PERCENT.
On the day of admission, abdominal girth was around 84 cm, and now at the time of discharge 70 cm ( that means the distension is also resolved)
And PATIENT WAS ADVISED TO
# stop alcohol.
# Take plenty of water.
PROBLEM THAT LEAD TO PRESENT ILLNESS:-
The patient is an occasional alcoholic drink with his peers (functions, parties:- 90-180ml).
But from 3 before the illness, the patient started drinking (binge drinking) (whiskey).
So the cause may be alcohol consumption.
ALCOHOL leading to pancreatitis:-
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6826792/
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