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PREFINAL -2022 APRIL

 I've 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 a diagnosis and treatment plan.


Name :- Kattekola Sathwik
Roll no :-58
2017 batch

A28yr old tailor hailing from Urban Telangana haspresented with complaints of pain abdomen since 2 days  

HISTORY OF PRESENTING ILLNESS

The patient was apparently in his normal state of health 8 years ago.Then he developed pain abdomen which was sudden in onset colicky type, aggravated on taking fatty food and relieved  on medication, for which he went to a local hospital where he was evaluated and he was diagnosed with Gall stones. Then he was referred to a higher centre where MRCP was done follwed by ERCPas a therapeutic procedure. After which he was apparently normal for some months following which he developed similar episodes of pain frequently (twice in 5 months)  for which consulted a local RMP for which he was given some medications (unknown). 
        About 2 days ago he was having a similar episode of pain abdomen which was continuous, colicky type, shooting to the back in standing position. It was relieved  temporarily after bending forwards for some time. He says that he feels more comfortable when he raises his legs or bends forward He also gives history of 2 episodes of vomiting which was projectile, and has food as content. 
No history of loss of appetite but he avoids taking food as pain aggravates  on consumption of food.
No history of jaundice, bowel disturbances, burning micturition and trauma 


PAST HISTORY
ERCP AND MRCP done for Gall stones 8years ago.
Images :-














No history of Diabetes ,hypertension ,asthma TB, epilepsy , CAD
PERSONAL HISTORY 
Appetite :- Good but avoids eating because of pain 
Diet :- Mixed 
Bowel and bladder :- Regular 
Sleep :- Adequate
Addictions:- nil

Family History:- No history  of similar complaints

General examination 
Patient was examined  in a well lit room after obtaining valid informed  consent and Adequate exposure
He was conscious, coherent, cooperative
Well oriented to time place person
Moderately built and nourished 
Pallor :- absent
Icterus:- absent 
Cyanosis:- absent 
Clubbing :- absent 
Lymphadenopathy:-absent 
Pedal edema:- absent 

Vitals 
Temperature :- afebrile
Respiratory rate :-14 cycles per minute
Pulse:- 86 beats per minute, regular,normal in volume and character, no vessel wall thickening, no radioradial delay
Blood pressure :- 130/80 mmHg  sitting position in right arm 


Systemic  examination  

PER ABDOMEN





Inspection
  • Umbilicus is central
  • Mild distension in Epigastric area and flanks are normal
  • Skin is normal and shiny 
  • Abdomen wall movements normal with respiration 
  • No engorged veins
  • No divarication of recti 
  • No visible pulsations
  • No visible peristalsis
  • No scars and sinuses
  • Herinal orifices are free
  • Cullens sign :-absent 
  • Gray turner sign:- absent 
  • Fox sign :- absent 
  • Bryant sign :- absent


Palpation

  • No local rise of temperature 
  • Tenderness on epigastrium 
  • All Inspectory findings  are confirmed
  • On deep Palpation, Liver, gall bladder and spleen are not palpable
  • No guarding , rigidity , palpable masses 
  • Murphys sign :- absent 
Measurements:-
Abdominal girth at level of umbilicus :- 33 inches  

Percussion :-
  • Tympanic note heard all over abdomen 
  • Shifting dullness absent 
  • Fluid thrill absent 

Auscultation:- 
  • Bowel sounds appreciated
  • No abnormal sounds heard 


Respiratory  system 

Inspection
Chest is bilaterally symmetrical
The trachea appears to be in centre
Apical impulse is not appreciated 
Chest moves equally with respiration on both sides
No dilated veins, scars or sinuses are seen

Palpation- 
Trachea is felt in midline
Chest moves equally on both sides on respiration 
Apical impulse is felt in the fifth intercostal space 1cm lateral to mid clavicular line
Tactile vocal fremitus- appreciated 

Percussion-
The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.
They are all resonant.

Auscultation-
Normal vesicular breath sounds are heard
No adventitious sounds


CARDIOVASCULAR SYSTEM- 
Inspection- 
The chest wall is bilaterally symmetrical
No dilated veins, scars or sinuses are seen
Apical impulse or pulsations cannot be appreciated 
Palpation-
Apical impulse is felt in the fifth intercostal space, 1 cm lateral to  the midclavicular line
No parasternal heave felt
No thrill felt

Percussion- 
Right and left borders of the heart are percussed 

Auscultation-
S1 and S2 heard, no added thrills and murmurs are heard 



CENTRAL NERVOUS SYSTEM-
HIGHER MENTAL FUNCTIONS:
Patient is Conscious, well oriented to time, place and person.


All cranial nerves - Intact

No signs of meningeal irritation


Motor system

                              Right.                  Left


BULK 

Upper limbs.        N.                         N

Lower limbs         N.                         N


TONE

 Upper limbs.       N.                        N

 Lower limbs.      N.                        N


POWER

 Upper limbs.      5/5.                    5/5

 Lower limbs      5/5.                    5/5



Superficial reflexes and deep reflexes are present, normal

Gait- normal

No involuntary movements


Sensory system- All sensations (pain, touch, temperature, position, vibration sense) are well appreciated

Provisional  diagnosis 
Acute pancreatitis secondary to Gall stones 

Investigations 

Pancreatic enzymes 
S. Amylase 124 IU/L(normal-13-60)

S. Lipase 528IU/L(normal-25-140)

HEMOGRAM-

HB 16.3grm/dl

TC 17,100cells/cumm (normal-4000-10000)

PLT 3.38

MCV 82.5

PCV 46

MCH 29.2

MCHC 35.4

SMEAR - NORMOCYTIC NORMOCHROMIC

BGT- O positive

RBS- 124

RFT-

Urea 50mg/dl (normal-12-42)

Creatinine 0.9mg/dl (normal-0.9-1.3)

S. Sodium 140mEq/L(normal-136-145)

S. Potassium 3.8mEq/L(normal-3.5-5.1)

S. Chloride 98mEq/L(normal-98-107)

LFT-

TB 1.38mg/dl (normal 0-1)

DB 0.45 mg/dl(normal-0.0-0.2)

AST 36 IU/L(normal-0-31)

ALT 21IU/L (normal-0-34)

ALP 117IU/L(normal-42-98)

TP 6.7gm/dl(normal-6.4-8.3)

ALB 3.73gm/dl(normal-3.5-5.2)


SEROLOGY: NEGATIVE


 BLOOD SUGAR LEVELS:

RBS-124mg/dl

USG  Abdomen
Chest X ray 
ECG 



Treatment

Diet :- 
On  30/3/2022 he was kept on Nill per mouth 
On 31/3/2022 he was given soft food

Medical management 
1. Inj . Tramadol
2. IV fluids  :- RL and NS  100 ml / hr 













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