40 yr old male with vomiting and abdominal pain

 13/10/21

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A 40 year old male presented with vomiting and pain abdomen.

K.Lasya Mithra, 9th semester

Roll No: 50

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.

CASE: 

 A 40 year old Male came to the causality with chief complaints of vomiting and abdominal pain since three days.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic three  days back then he had a heavy fatty meal followed by vomiting  4- 5 episodes which has food as content , non- bilious,  non- projectile.

 He also complained of  pain in upper abdomen which is insidious in onset , squeezing type , non radiating, aggravated on food intake and relieved after episode of vomiting and on bending forward. 

No history of loose motions, fever, decreased urine output,  shortness of breath,  pedal edema, chest pain, numbness, muscle spasms.

PAST HISTORY:

He had similar complaints 6 months back for which he was treated in our hospital. 

Not a known case of diabetes, hypertension,  asthma,  epilepsy , tuberculosis.

Past surgical history- appendectomy 20 years back. 

PERSONAL HISTORY: 

Appetite- normal 

Diet- mixed

Bowel and bladder- regular

Sleep - adequate 

Addictions - 

history of alcohol intake from 15 years , 180 ml per day , abstinence from 1 month.

CAGE criteria: score - 1

1. Have you ever felt you needed to Cut down on your drinking - no
2. Have people Annoyed you by criticizing your drinking - no
3. Have you ever felt Guilty about drinking - no
4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover - Yes

History of Smoking from 15 years , 4- 5 cigarettes per day.

No history of drug and food allergies. 

FAMILY HISTORY: insignificant

 GENERAL EXAMINATION:

patient was examined in a well lit room after taking consent.

 

Patient is conscious,  coherent and cooperative.

pallor - absent 

icterus - absent

Cyanosis - absent

Clubbing - absent

No lymphadenopathy 

No pedal edema.

Vitals:

Temperature: 99F

BP :160/110 mmHg

PR : 98bpm

RR: 22 cpm

SpO2 98% in room air

SYSTEMIC EXAMINATION:

CVS: S1 S2 heard

         No thrills and murmurs

RS : trachea central

        BAE- present 

        Normal vesicular Breath sounds

CNS: No focal neurological deficits

P/A : soft , non tender

          Umbilicus - inverted

          All quadrants moving equally with      respiration

          Scars- vertical scar seen below umbilicus on right side ( appendectomy scar)

          No palpable spleen and liver

          Normal bowel sounds heard.

INVESTIGATIONS:

CBP:

Hb - 12.3 gm/dl

TLC -  9400 cells/ cumm

RBC - 4.5 million

PLT - 4.5 lakh

PCV- 37.7

Amylase - 79 IU/L

Lipase - 28 IU/L

RFT: 

urea - 79 mg/dl

Creatinine - 1.5 mg/dl

eGFR - 51.8

Electrolytes:

Na  - 145 mEq/L

K - 4.1 mEq/L

Cl -  98 mEq/L 

LFT :

 Total bilirubin- 1.36 mg/dl

 ALT - 26 IU/L

 AST - 38 IU/L

 ALP - 153 IU/L

 albumin - 3.5 gm/dl

 A/ G ratio - 1.35

CUE :

Clear, pale yellow 

Pus cells : 3 - 4 

Albumin - nil

RBC , casts - nil

X- RAY

 

USG :

ECG :  

PROVISIONAL DIAGNOSIS: 

Acute pancreatitis with Acute kidney injury

TREATMENT:

Day 1

• IV Fluids - NS and RL - 100 ml/hr
• Inj. PAN - 40 mg  IV , OD
• Inj. BUSCOPAN - 10 mg , IV  
• NBM
• GRBS monitoring
• BP monitoring 4 hrly
• Monitor I/O

Day 2

vitals:

• BP : 110/70 mm Hg
• PR : 90 bpm

O/E :

• CVS - S1,S2 heard
• RS - BAE - present
• P/A - soft, non-tender

Treatment:

• IV Fluids - NS and RL - 100ml/hr
• Inj. PAN - 40 mg ,IV, BD
• Inj. BUSCOPAN 10 mg, IV
• Soft oral diet
•  BP monitoring 4th hrly
• Inj. TRAMADOL 
• I/O monitoring