Short case final practical

 General medicine final practical:- short case: 

 This is an online E log book to discuss our patient's   

de-identified health data shared after taking 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 patient's clinical problems with collective current best evidence based inputs.

MUSKAAN GOYAL 

Hall ticket no. 1701006120


DEIDENTIFICATION : 

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.


CONSENT : An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references. 

 DOA: 7/6/2022

A 22yr old male  pt. painter by occupation resident of nalgonda came with 

Cheif complaints:

Pain abdomen since 4 days.

HOPI:


Course of illness


Pt. Has started consuming alcohol 4 yrs back due to peer pressure , intially taking one peg per day which has increased to 90ml morning and evening i. e twice daily.  He has stopped consuming alcohol 3 months back as advised by the doctor.

Pt. Has history of smoking since 2 yrs . He has been smoking beedies 5 per day till date.

Pt was apparently asymptomatic 3 months back then he developed abdominal pain which was dragging in character for which he was admitted in near by hospital in nalgonda . He was diagnosed with acute pancreatitis and was treated inadequately  and was advised to stop consumption of alcohol. 

Since then pt has stopped consuming alcohol and has been experiencing alcohol withdrawal symptoms like  getting angry , agitation , irritability , craving to consume alcohol, tremors . Pt had consumed alochol 4 days back due to fight with his wife.

In veiw of this symptoms pt.has been brought to psychiatry OPD for deaddiction. He was referred to medicine OPD in veiw of pain abdomen.

Pain was , insidious in onset , started after consuming of alcohol in epigastrium and left hypochondrium which was relieved on bending forward and lying down , aggregated on eating food and standing straight.

No h/o fever , nausea , vomiting.

No h/o chestpain , shortness of breath , constipation

Flatus passed

Past history:

H/o similar complaint in past 3 months back.

No other co morbid conditions

No h/o previous medical surgical history. 

Family history :

Not significant 

Personal history 

Diet : mixed 

Appetite : normal

Bowel bladder: regular 

Sleep: inadequate 

General examination:

Pt was concious coherent and cooperative

Thin built and moderately nourished

Pallor - present

No icterus,cyanosis , clubbing,lymphadenopathy, edema








Nasogastric tube has been placed which is attached to the bag


Vitals at the Time of admission

Temperature- afebrile

Pulse rate- 94bpm

Blood pressure-120/80mmHg

Respiratory rate- 16cpm

Systemic examination:

Abdominal examination:

Inspection:

Shape of the abdomen- flat

Umbilicus is central

No visible scars,pulsations, peristalsis, engorged veins

Palpation:

All the inspectory findings are confirmed.

Tenderness present over the epigastrium  and left hypochondrium region

Liver palpable 2cms below costal margin

Liver span: 11.5cm ( normal)

Spleen : not palpable 

Kidney : not palpable

Percussion:

No free fluid

Ascultation:

Bowel sounds heard 


 Other systems: 

Respiratory:

 b/l air entry present  , no added breath sound

CVS : 

S1 S2 heard , no added murmurs 

CNS : 

Higher function intact 

No motory and sensory deficit.

Cranial nerves normal .


Investigations:

USG abdomen

Serum amylase : increased to more than three times

Serum lipase







Other tests : 

Hemogram 

RBS 

RFT 

LFT 

Blood grouping 






Diagnosis: 

Pseudocyst of pancreas secondary to unresolved acute pancreatitis.


Treatment:

Nil per oral

IV fluids Ringer lactate ,Normal saline 100 ml per hour

Inj. Tramadol100mg in 100ml NS IV BD

Inj.pantop 40 mg IV OD

Inj. Optineurin 1 ampoule in 100ml NS IV OD

Psychiatry medication

Tab . Lorazepam 2mg BD

Tab . Benzothiamine100mg OD

















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