Case 19 - A 65 year old man with abdominal pain since 5 days.

A 65 year old man with abdominal pain since 5 days.

Hi, I am R. Ramya Keerthana, 5th semester medical student. 

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 patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs 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.  

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.

Case Scenario

AMC Bed 4

DOA: 24-06-23

A 65 year old man resident of Nalgonda came to OPD with chief complaints of: 

- abdominal pain since 5 days.

History of Presenting Illness

- patient was apparently asymptomatic 1 year ago when he developed pain in the right hypochondrium and yellow discoloration of sclera. He visited a local physician and was diagnosed with gallstones for which he was prescribed medication for 15 days following which his symptoms subsided.

- 1 week ago he experienced pain in the abdomen for which he went to a local physician who prescribed medication following which his symptoms subsided.

- 5 days ago, he came to our OPD with complaints of:

1. Abdominal pain after drinking 750ml alcohol and eating oily food. Pain is in the epigastrium, sudden onset, continuous, burning type, radiating to the back, aggravated on food intake, not relieved on medication and associated with bloating and belching.

2. He had 2-3 episodes of vomiting, non-projectile and non-bilious, 5 days ago 

3. Fever 5 days ago, high grade, continuous, relieved on medication but relapsed after 2 days.

- no h/o dysphagia, loose stools, chest pain, SOB, headache, blurring of vision, burning micturition, reduced urine output, rashes or itching on skin.

Daily Routine

- he wakes up at 6am and has breakfast(rice and curry) and tea at 9am and goes to work in the animal shed. He has lunch (rice and curry) at 2pm and works till 7pm before returning home. He has dinner (rice and curry) at 8pm and goes to sleep at 9 pm.

Past History

- h/o knee pain since 15 years for which he uses herbal medicine, pain worsens on exertion.

- n/k/c/o HTN, DM, TB, CAD, epilepsy, asthma, thyroid disorder

- no h/o of blood transfusions.

Surgical History

- right inguinal hernia surgery 20 years ago.

Personal History

- married

- Used to work as a toddy collector but stopped working since 5-6 years due to lack of energy 

- mixed diet 

- decreased appetite

- adequate sleep

- normal bowel movements 

- normal micturition

- no known allergies

- sutta addiction since 50 years, stopped since 1 year ago 

- chronic alcoholic (toddy) since 50 years, 1/2 bottle per day, stopped since 4 days ago.

Family History

- not significant 

Drug History

General Examination

I have examined the patient after taken prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room. 

- patient was conscious, coherent and cooperative

- well oriented to time and space

- well built and adequately nourished

- no pallor

- no icterus

- no cyanosis 

- no clubbing of fingers

- no lymphadenopathy 

- no pedal edema 

- no malnutrition 

- no dehydration 

Vitals

- Temperature: afebrile 

- Pulse rate: 80 bpm, regular rhythm, normal volume

- Respiratory rate: 16 cpm

- BP: 110/70 mm Hg

- SPO2: 99% at RA

- GRBS: 155 mg/dl

Fluid Intake and Urine Output

Total Input: 1700 ml

Total Output: 950 ml

Fever Chart

Systemic Examination

CARDIOVASCULAR SYSTEM

Inspection : 

-Shape of chest: elliptical 

-No engorged veins, scars, visible pulsations

Palpation :

-Apex beat can be palpable in 5th intercostal space

- no cardiac thrills 

Auscultation : 

- S1,S2 are heard

- no murmurs

RESPIRATORY SYSTEM

Patient examined in sitting position

Inspection:

- Upper respiratory tract - oral cavity, nose & oropharynx appear normal. 

-Chest appears Bilaterally symmetrical & elliptical in shape

- No dyspnea and wheezing 

-Respiratory movements appear equal on both sides and it's abdominothoracic type. 

-Trachea central in position & Nipples are in 5th Intercoastal space

-No dilated veins,sinuses, visible pulsations.

Palpation:

-All inspiratory findings confirmed

-Trachea central in position

Percussion: Resonant 

Auscultation:

-Supraclavicular- (NVBS) (NVBS)

-Infraclavicular- (NVBS) (NVBS)

-Supraammary- (NVBS) (NVBS)

-Inframammary- (NVBS) (NVBS)

-Axillary- (NVBS) (NVBS)

-Infra axillary-(NVBS) (NVBS)                 

-Suprascapular- (NVBS) (NVBS)

-Interscapular- (NVBS)

-Infrascapular- (NVBS)(NVBS)

ABDOMEN 

- shape: obese

- diffuse tenderness present 

- no palpable mass

- no bruits

- no free fluid

- hernias orifices: normal

- liver: not palpable 

- spleen : not palpable

- bowel sounds heard

- genitals:

- speculum examination :

- P/R examination : 

CENTRAL NERVOUS SYSTEM

- conscious 

- normal speech

- no neck stiffness

- no Kerning's sign

- cranial nerves: normal

- sensory : normal

- motor: normal

- reflexes: all present bilaterally

- finger nose in coordination: no 

- knee heel in coordination: no

- gait: normal

Investigations

Biochemical:

24-06-23

25-06-23

26-06-23

27-06-23

28-06-23

USG:

ECG: 

Chest X-Ray PA View:

Erect Abdomen X-Ray:

Provisional Diagnosis

- ACUTE PANCREATITIS

Treatment