1801006064 SHORT CASE



 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.



This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


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.

A 38 year old male , who is a civil engineer by profession and resident of West Bengal came to  OPD with chief complaints of :

             Abdominal pain since 5years
   
HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 5 years ago then he developed abdominal pain  which was sudden in onset and progressive in nature.
Pain occured once in every 3 months in the past 41/2 years but since 6 months he is having pain once in a month.pain  is radiating to the back and dragging type of pain.
It aggravates  on taking alcohol and relieved on medication.

 Since  1 year he  had episodes of vomiting  which was  non bilious ,non projectile and water as content followed by abdominal pain
Associated with weakness and giddiness.

He also complained  of severe weight loss. He was 86 kgs 6 months ago but at present he reduced to 67 kgs.

He also has history of depression for which he is attending psychiatric counselling sessions.

Daily routine: He wakes up at 6am in the morning , gets ready and have breakfast ,go to the office ,completes his work and returns by 5pm  and plays badminton or football and then comes to home ,have dinner at 8pm and goes to bed by 10pm.

PAST HISTORY:
History of trauma to nose in childhood while playing football and is having deviated nasal septum to left side which is not affecting his respiration
Episode of jaundice when he was 12 yrs old
Not a known case of DM, HTN,asthma,TB,epilepsy 
History of appendicectomy when he was 17 yrs old

FAMILY HISTORY: No significant family history.

PERSONAL HISTORY:


DIET- Mixed

APPETITE- Normal. 

SLEEP- inadequate

BOWEL AND BLADDER Regular

ADDICTIONS-

ALCOHOL- 180 ml every day since 20years .He had stopped consuming alcohol from 6 months because it increases the severity of abdominal pain.


SMOKING- 2 packs a day  when he was in college. 1 pack a day from 6 months.

ALLERGIES- no allergies

GENERAL EXAMINATION:

Patient was conscious , coherent ,cooperative 

moderately built and nourished

Vitals:

Temperature - Afebrile

PR :- 80 bpm

RR :-16 cpm

BP :- 110/70 mm Hg

SPO2 :- 98%

Pallor: present

Icterus: absent

Cyanosis: absent

Clubbing: absent

Generalised Lymphadenopathy:absent

Pedal edema:Absent

SYSTEMIC EXAMINATION:

CVS-S1, S2 heard,no murmurs

Respiratory System:-

 BAE- present 

NVBS- heard

Per abdomen:-

 soft , non tender.

CNS- no focal neurological deficits









 


PROVISIONAL DIAGNOSIS
Chronic pancreatitis secondary to alcoholism

INVESTIGATIONS

Hemogram 

Hemoglobin 11.2g/dl

RBC count 4.27 million/mm3 

Platelets 2lakhs /mm3 

Total count 4700/mm3 

Eosinophils 02%

Basophils 00

Neutrophils 64%

Monocytes 02%

Lymphocytes 22%

Liver function tests 

Total  bilirubin 1.53mg/dl

direct bilirubin 0.25 mg/dl

SGOT 42 IU/L

SGPT 72 IU/L

Alkaline phosphatase 1242 IU/L

Total protein 5.8g/dl

Albumin 2.9g/dl

A/G ratio 1.28

Renla function tests 

Urea 25 mg/dl
Urice acid 4.5 mg/dl
Creatinine 0.9mg/dl
Serum electrolyte
 Sodium 136 mEq/L
Phosphorus 3 mg/l
Potassium 3 .6 mEq/l
 Calcium9.2 mg/l

Serum Amylase 172 IU/L Normal 25 to 140 IU/L
Serum Lipase 72 IU/L Normal 13 to 60 IU/L
 CT scan Abdomen

Findings
Bulky head and uncinate process of pancreas with heterogeneous cystic areas within with surrounding mild  fat stranding and fluid.Small calcific focus along anterior surface of body of pancreas.Thin pancreatic body and tail with mildly dilated main pancreatic duct





Treatment 

Inj. Tramadol 1 amp in 100 ml NS OD 
TAB. Thiamine 100mg BD 
IV fluids NS , RL @ 75ml/hr 
Tab. Pantop 40mg OD
 


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