174 P.Tharun

General medicine  E - LOG Book     

Final practical exam:short case 

P.tharun 

Hall ticket number:1701006135

 

This is an online E log book to discuss our patient's de-identified health data shared after taking his/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

CASE PRESENTATION :

A 22years old male patient came to opd with chief complaint of following

Pain abdomen since 4 days ago 

History of present illness :

Patient was apparently assymptomatic 4 months back ; then he developed vomiting and pain abdomen presented in hospital and diagnosed as acute pancreatitis;he was treated and On discharge he was advised to stop drinking alcohol

Then 4 days later he developed pain over abdomen which is of dragging type,radiating to back,aggravated pain when lying on back 

No history of vomiting,diarrhoea

Patient had alcohol withdrawal symptoms after pancreatitis episode and is willing to take up de-addiction treatment 

Past history :

Not a known case of diabetes mellitus,asthma, tuberculosis, hypertension, epilepsy, cardiovascular diseases 

Family history :

 not significant

Personal history:

Diet is of mixed type

Appetite reduced

Sleep is adequate

Bowel and bladder movements are regular

Addiction : started drinking alcohol 4 years back 

Later his habit of drinking became a daily habit for 3 years 

General physical examination:

Patient is concious , cooperative and well oreinted with time place and person 

His appearance is of thin built body 

Pallor and edema present 

No signs of icterus cyanosis clubbing and lymphadenopathy

Vitals:

 Patient is afebrile

Respiratory rate :14 cpm 

Pulse rate : 92 bpm 

Blood pressure : 110/80 mm of Hg

SYSTEMIC EXAMINATION :

ABDOMEN EXAMINATION :

Inspection shows following

Shape - flat

Centrally placed umbilicus 

 No visible pulsations  

No scars, draining sinuses,dilated veins and hernial orifices 

All abdominal quadrants are moving equally with respiration

 

Palpation :

On Percussion over abdomen tympanic note is heard 

There is no shifting in dullness

There is no fluid thrill

Auscultation : 

Bowel sounds are heard 

Respiratory system : bilateral air entry is observed,no added sounds 

Cardiovascular system : S1,S2 are heard 

No murmurs 

Central nervous system  :

Higher function intact

Cranial nerves are normal 

Sensory and motor systems are intact 

Investigations : 

 Heamogram : 

   Heamoglobin - 11.8 mg/dl

   Total leucocytes count - 14,300 cells/cubic mm 

Lymphocytes - 16

  

Provisional diagnosis:

 Pseudocyst of pancreas

Treatment :

  Nill by mouth

  Intravenous fluids Ringer lactate & normal saline 10ml/hour 

Inj Pan 40 mg.iv BID

 Inj.Tramadol 100 mg in 100ml normal saline IV BD

Inj.Optineurin iv BD

Inj.Zofer 4mg iv BD

Psychiatric medications : 

Tab.Benzothiamine 100 mg OD

Iv lorazepam 2mg BD