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 ILLNESSThe 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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