1802102088 Long case

 February 9, 2022

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Date of admission: 7/2/2022

A 27 yrs old male patient presented to the opd with chief complaint of pain in the abdomen since 3 months.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 3 months back,  then developed pain in the left hypochrondrium region.

In the month of November patient had undergone a trauma, thereby developed pain in the left hypochondrium region . The pain was also associated with vomitings containing food particles.

Patient visited nearby hospital and was suggested on medication , the pain subsided on use of medication

After few days patient again complains  of pain and visited nearby hospital

The pain did not relieve on use of medication and aggrevated since then.

Since last 3 days patient complains of severe pain which aggrevates on walking , standing and prolonged sitting and relieves on bending forward.

Pain is intermittent in nature, squeezing type and radiated towards the back and left shoulder

Patient was tested postive for covid in the month of January.

PAST HISTORY:

No history of diabetes, hypertension, asthma

No history of any surgeries in the past

PERSONAL HISTORY:

Diet - mixed

Appetite- reduced since 10 days

Sleep- inadequate

Bowel and bladder movement- irregular

Patient gives a history of high alcohol intake since 5 years , regular intake in high amount.

FAMILY HISTORY: 

No history of similar complaints in the family

GENERAL EXAMINATION:

Patient is conscious , coherent and cooperative

No pallor , no icterus, no clubbing, no lymphadenopathy

VITALS:

Temperature- afebrile

Pulse rate- 84bpm

Respiratory rate- 16 breaths/min

BP- 100/80mmHg

SYSTEMIC EXAMINATION:

CVS:

S1S2 heard

No cardiac murmurs

RESPIRATORY SYSTEM:

No dyspnea

No wheeze

Position of trachea- central

ABDOMEN-

Tenderness - present

Shape of abdomen- scaphoid

Spleen not palpable

Bowel sounds are present

CNS:

Level of consciousness- conscious

Speech - normal

No neck stiffness

INVESTIGATIONS:

Hemogram:

Hb=10.5 gm/dl

PCV=#32.5

Liver function test:

Total bilirubin- 0.48mg/dl

Direct bilirubin- 0.17mg/dl

SGOT=13 IU/L

SGPT=14 IU/L

Alkaline phosphatase= # 291IU/L

Total proteins- #5.9gm/dl

Albumin # 2.9gm/dl

A/G ratio =0.98

Serum amylase=292

CRP POSTIVE 2.4mg/dl

PROVISONAL DIAGNOSIS:

Chronic pancreatitis with pseudocyst

TREATMENT:

1. IVF NS/RL - 75ml/hr

2. Inj Tramdol 100ml IV/TID

3. Inj Pantop 40mg IV/OD

4. Inj.zofer  4mg IV/SOS