38 yr old with Pain Abdomen

A 38yr old male resident of West Bengal , civil engineer by occupation came to the OPD with chief complaints of abdominal pain since 5 years

HOPI :-

Patient was apparently asymptomatic 5 years back then developed pain abdomen which is sudden in onset , gradual in progression , dragging type radiating to back which aggravates on intake of food, alcohol and relieved on medication. 

From last 5 years he has episodes of abdominal pain occurring once in 3 months later from last 6 months pain occurs more frequently/daily?

For the past 1 year patient has episodes of vomiting followed by pain in abdomen at least once in 2 months which is non bilious and water as content associated with weakness and giddiness

On13th November he had multiple episodes of vomiting after lunch, initially vomiting containing food particles (yellowish)  later watery associated with weakness and giddiness and not relieved on medication.

On 23rd November he had similar episode of pain and took medication

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

He also complains pain at elbow on long hours of working( writing/playing)

H/o accident 1 year ago, injured at elbow and knee, dental injury

Patient also complains of constipation and per rectal bleeding since childhood.

Daily routine: He wakes up at 6am in the morning , 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:-

Known case of haemorrhoids since 12 years of age

History of jaundice when he was 12 years old which later subsided

History of trauma to the nose while playing football during childhood (15 years) and developed Deviated nasal septum towards left side.

H/o Appendicectomy when he was 17 years old

H/o leprosy 12 years ago

N/K/C/O DM, Hypertension,TB, Asthma, epilepsy 

H/o psychiatric problem- depression, insomnia which not subsided on medication

Family History:-

Not Significant 

Personal History:-

Diet - Mixed

Appetite - Normal. 

Sleep - Inadequate

B&B - Bowel - constipation since 12 years old

            Bladder movements normal

Addictions - Alcohol - 180mL to 375mL everyday from 10 years. From last 6months he decreased consuming alcohol

Smoking - Initially 2 packs per day back when he was in college later  1 pack per day

Allergic History :-

Not allergic to any food or drug

Treatment History:-

Anti anxiety drugs

Medications to induce sleep- atiavin 2mg

Ayurvedic medicine( Jandu?) for constipation 

Pancreotid, pantocid dsr, creotox previously 

Tramadol for pain

REFERRALS

Ortho - Olecranon buristis

Ophtho - for lacrimation , gave eye drops

Ent - for dns , suggested septoplasty 

Dental referral - for tooth injury, scaling done

GENERAL EXAMINATION -

Patient was conscious, coherent, cooperative and well oriented to time, place and person

Moderately built and nourished 

Pallor , icterus , cyanosis , clubbing , lymphadenopathy , edema - ABSENT

Vitals-

Temperature 94F

PR :-  80bpm

RR :-  16cpm

BP :-  110/70 mmHg

SpO2 :- 98%

SYSTEMIC EXAMINATION:-

CVS - S1 , S2 heard, No murmurs

RS - B/L airway entry + , Normal vesicular breath sounds - heard 

CNS - No focal and neurological deficits

P/A 

 Inspection: Not distended , umblicus inverted , No discharging sinus seen, Scar in the RIF ( Appendicectomy)

Palpitation :  No local rise in temperature, Mild tenderness in epigastric region, No organomegaly

Percussion: tympanic

Auscultation: Bowel sounds audible 

BURSA can be felt on palpitation at elbow and hip areas

INVESTIGATIONS:-

CT ABDOMEN:-

USG Right elbow-

Features of mild Right Olecranon bursitis 

Ulnar nerve - normal

Left Olecranon fossa - normal

No joint effusion

PROVISIONAL DIAGNOSIS:

Chronic Pancreatitis 

Left sided DNS

Rt elbow bursitis? (Olecranon bursitis)

TREATMENT:

1.T.ULTRACET

2.BP MONITORING

3.VITALS MONITORING 6TH HRLY