35yr male with pancreatitis and hypertension

 K.Ankitha

Rollno : 78

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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 diagnosis . 

CHEIF COMPLAINTS :

Patient was brought to casuality with chief complaints of  pain abdomen since 1 day 

HOPI  :

Patient was apparently asymptomatic untill yesteday afternoon . He then had Pain abdomen which was insidious in onset and gradually progressive (pain in all areas) associated  with nausea and vomitings.

• C/O  vomitings - 10 episodes yesterday and no vomitings today, watery in nature , non projectile, Bilious with food particles as content , non blood tinged.
• C/O Fever since 1 day - low grade,intermittent , no chills and rigor and relieved on medication (subsided now)
• C/O SOB - Insidious in onset , gradually progressing 
  SOB at rest
• C/O abdominal distension and discomfort.

 No C/O loosestools ,burning  micturition , chest pain.

PAST HISTORY : 

No similar complaints in the past.

• K/C/O Hypertension since 3 years on irregular medication (using Amlong 5mg + Aten 50mg od )
• Not a K/C/O DM/ TB/ CVA /CAD/ Epilepsy /Thyroid disorder

PERSONAL HISTORY :

Diet : mixed

Appetite : normal

Sleep : normal

Bowel and Bladder : Regular

No allergies

Addictions : Regular Alcoholic since 7-8 years

(Last alcohol intake yesterday morning) 

Tobacco chewing since 7-8 years  

FAMILY HISTORY :

Insignificant

Course in hospital :

Orthopaedics referral was done i/v/o Bilateral Knee Pain ans swelling .

Usg B/L knee :

Xray Knee Joint :

Under Aseptic conditions , from Rt knee through suprapatellar approach about 97ml of synovial fluid is aspirated and sent for investigations.

GENERAL EXAMINATION :

Patient is conscious , coherent , cooperative 

Moderately built and nourished .

No signs of pallor , icterus , cyanosis , clubbing , lymphadenopathy , edema.

VITALS :

Afebrile.

PR - 98bpm

BP - 130/80 mmhg

RR - 20 cpm

SpO2 - 98% on Room air

GRBS - 213mg%

SYSTEMIC EXAMINATION :

PER ABDOMEN :

Inspection :

Abdomen is obese

Umbilicus is central

All quadrants are moving equally with respiration 

No sinuses , engorged veins, visible pulsations .

Hernial orifices are free.

Palpation :

No local rise of temperature 

Tenderness present in epigastrium and right hypochondrium

Liver and Spleen - Not palpable 

Percussion : Tympanic note heard over the abdomen.

Fluid thrill absent

Shifting dullness absent

Auscultation :

Bowel sounds are heard.

CARDIOVASCULAR SYSTEM : 

Inspection:

Shape of chest is elliptical. 

No raised JVP

No visible pulsations, scars , sinuses , engorged veins.

Palpation :

Apex beat - felt at left 5th intercostal space

No thrills and parasternal heaves

Auscultation :

S1 and S2 heard.

RESPIRATORY SYSTEM:

Inspection: 

Shape- elliptical 

B/L symmetrical 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 

Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 

Auscultation:

bilateral air entry present

Wheeze present

CENTRAL NERVOUS SYSTEM:

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 

Motor system:

Tone- normal

Power- bilaterally 5/5 

Reflexes Right  Left

Biceps      ++        ++

Triceps.   ++.        ++

Supinator ++       ++

Knee.         ++.      ++

Ankle        ++.       ++

INVESTIGATIONS

Hb - 11.7g%

TLC - 11,000

Platelet - 2.0

RBC - 4.0

Impression : Neutrophilic leucocytosis

 

Usg abdomen : 19/03/23

21/03/23 : 

Review Usg :

22/03/23 : 

23/03/23 :

PROVISIONAL DIAGNOSIS  :

ACUTE PANCREATITIS secondary to alcohol With K/c/o HYPERTENSION since 3 years 

With ? Septic arthritis Rt Knee joint ? Acute Gout 

With ? Chronic liver disease

 TREATMENT : 

1. Soft diet
2. IV Fluids - 1 unit NS , 1 unit RL @100ml/hr                        
3. Inj. Tramadol 1 amp. In 100 ml NS IV/TID
4. (D6) Inj. Thiamine 200mg in 100ml NS IV/TID
5. Inj. PANTOPRAZOLE 40mg IV/OD
6. Inj. Z0FER 4 mg IV/SOS
7. Inj. PCM 1gm/IV/SOS 
8. Tab.PCM 650mg PO/SOS
9. Tab. Amlokind AT (5+50) PO OD.
10. Tab.UDILIV 300mg PO/BD
11. Tab. RIFAGUT 550mg  PO/BD 
12. Tab. CHYMEROL FORTE PO/BD 
13. Syp. HEPAMERZ 15ml PO/BD 
14. Syp. LACTULOSE 15ml PO/BD 
15. Oint. THROMBOPHOBE for L.A
16. Grbs, Vitals monitoring 4th hrly and inform sos