45yr old male with acute pancreatitis
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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 come up with diagnosis and treatment plan.
NAME : ANKITHA
ROLL NO : 78
This is a case of a 45 year old male, carpenter by occupation came to OPD with chief complaints of:
1. Pain abdomen since 2 days
2. Vomitings since 2 days
3. Constipation since 3 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 2 day ago then he developed pain in the abdomen- in epigastric region.
It was sudden in onset, gradually progressive.
Pain more after eating food and on lying in supine position.
Pain relieved on sitting , on bending forward.
Yesterday he went to a local rmp and took medication but pain did not subside so came to our hospital today
-H/O 3 episodes of Vomiting yesterday after eating food, food as content, non bilious, non projectile, not blood tinged.
-Constipation since 3 days
Last binge of alcohol consumption 2days ago.
No H/O fever, cough, cold, shortness of breath, loose stools, giddiness , burning micturition
PAST HISTORY:
H/O similar complaints 2 years ago- diagnosed as Acute pancreatitis, treated at KIMS Narketpally
No significant family history
SYSTEMIC EXAMINATION:
PER ABDOMEN :
Inspection :
Abdomen is scaphoid
Umbilicus is central
All quadrants are moving equally with respiration
No sinuses , engorged veins, visible pulsations .
Palpation :
No local rise of temperature
Tenderness present in epigastric region
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 ++. ++
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