1801006118 - SHORT CASE

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. This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. 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

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 10days 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. 

 H/o episodes of vomiting followed by pain in abdomen at least once in 2 days which is non bilious and water as content associated with weakness and giddiness

 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 

He also complains of severe weight loss.

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

Tramadol for pain




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), no dilated veins.

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


PROVISIONAL DIAGNOSIS :  acute pancreatitis




INVESTIGATIONS:-


CBP

HB 11.2 gm/dl

total count      4700 cells/Cumm

Neutrophil       64%

Lymphocytes. 22%

Monocytes.      2%

Basophils          1%

Smear               normocytic normochromic



Liver functional test

Total Bilirubin 1.53mg/dl

AST 42 IU/L

ALT 72 IU/L

ALP 1243 IU/L

Total proteins  5.3gm/dl

Albumin 2.98GM/DL



Serum lipase 72IU/L

Serum amylase  176 IU/L

Usg:



CT ABDOMEN:-












USG Right elbow-






Features of mild Right Olecranon bursitis 

TREATMENT:

1.T.ULTRACET

2.BP MONITORING

3.VITALS MONITORING 6TH HRLY






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