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I thank Dr. Chitra , for providing me with every detail about the patient , and also being extremely patient with my doubts about the case.
Introduction :
The Patient is a 27 year old Male , a Post Office Employee in Telangana .
Chief Complaint :
The Patient presented to the Casualty on 5th June 2021 with complaints of Pain in Upper Abdomen since the morning of that day.
History of Presenting Illness :
( Certain Past Events shall also be mentioned here , if they have a role in the present manifestation of the pathology )
The patient has been an Alcoholic since 5 years , with a daily intake of about 180 ml of Whiskey .
The Patient developed pain in the Upper Abdomen in the early morning hours of 5th June 2021 and was rushed to the hospital.
Pain was sudden in onset , rapidly progressing , aggravated ( burning sensation ) by spicy/heavy food intake , no relieving factors as such.
He described the pain to be diffuse , radiating to the back .
Not associated with
Nausea/ Vomiting
Shoulder Tip Pain
Distended Abdomen.
Last History of Alcohol Intake : 2nd June 2021
Past History :
No similar Complaints of Acute Abdominal Pain in the past,.
In 2014, he had had an acute attack of SOB,triggered by cold exposure , had got relieved on medication .
He was prescribed Inhalers but is not compliant to the same.
In 2015, he had an episode of Epilepsy , for which he is under medication .
He is not a K/C/O DM , HTM , CAD .
Personal History :
Appetite is normal ,
Takes Mixed Diet,
Bowel and Bladder : Normal
Sleep : Adequate
Does not Smoke
Is a Regular Alcoholic since 5 years ( details mentioned above )
No known food or drug allergies .
He is less tolerant to cold exposure / cold food/drinks . (Asthma Trigger )
Family History :
Not Significant.
Treatment History :
Has had a Surgical repair for Inguinal Hernia 4 years ago.
NOTES :
EXAMINATION :
GENERAL EXAMINATION :
The patient was examined in both sitting and supine position after obtaining Consent . Examination was done in a well lit room , in the presence of an attendant , with adequate exposure .
Patient in Pain .Wincing Expression . ( Wong Baker's Rating : 8 ) .
Patient is not still on bed.
The patient is of moderate nutrition and built.
TRUNCAL OBESITY PRESENT.
Conscious , Coherent , Cooperative . Oriented to time , place and person.
He does not have
Pallor, Icterus , Cyanosis , Koilonychia , Clubbing ,Generalised Lymphadenopathy ,Pedal Edema.
VITALS on Presentation :
Pulse : 110 bpm , normal Rythm , volume , condition of vessel wall , without any delay.
B.p : 130 / 80 mm Hg recorded in the Right Brachial Artery in supine position
R.R : 22 cpm
Body Temp. : Afebrile .
SpO2 : 98 % on r.a.
Pain : Present , Rating 8 ( Wong Bakers Rating ).
SYSTEMIC EXAMINATION :
CVS : normal
RESPIRATORY SYSTEM : normal
CNS : normal
ABDOMEN : Abdomen soft , tender.
RESPIRATORY SYSTEM : normal
CNS : normal
ABDOMEN : Abdomen soft , tender.
Note : Tender Abdomen .Abdomen is distension has increased . On 6/June/2021 night : Resonant note was obtained up to 3 cm above the umblicus but
On 7/jun/2021 morning : Resonant notes percieved till below the umblicus.
Shifting Dullness present .
INVESTIGATIONS :
Complete Blood Count
Urine Sample
COMPLETE URINE EXAMINATION
COAGULATION PROFILE :
LDH raised
SERUM LIPASE raised
SERUM AMYLASE raised
Normal Random Blood GLucose
CHEST RADIOGRAPH
RYLE'S TUBE ASPIRATE.
FEVER CHART
CROSS CONSULTATION NOTES :
Provisional Diagnosis : A 27 year old man , chronic alcoholic with acute pancreatitis and Grade II Steatohepatitis .
INTERVENTIONS DONE :
Plan of Management : Conservative.
Communication with Attenders : Outcome has been adequately explained .
Medications :
UPDATED : ( 9th June 2021 )
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