45/M with cc pain, constipation and vomitings

 

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A 45 year male patient resident of guduru occupation carpenter came to opd with chief complaints of 

• Pain in abdomen since 3 days 
• Constipation since 3 days 
• Vomiting since 2 days 

History of present illness: 

Patient was apparently asymptomatic since 3 days back, then he developed pain in the abdomen ( epigastric region) which was sudden in onset, gradually progressive in nature,radiating to the back, aggravating on consumption of food and on lying in supine and relieved on sitting or bending forwards.

Pt. also complaints of inability to pass stools since 3 days,

H/o vomitings 2 days ago, 3 episodes, after consumption of food, contains food particles, it was non-projectile, non-bilious and not blood tinged.

No H/O dysphagia , heart burn , abdominal distestion , melena , weight loss .

No H/O fever, cough, cold, shortness of breath, loose stools, giddiness

H/o of binge  alcohol consumption 2days ago.

Daily routine

PAST HISTORY:

H/O similar complaints 2 years ago- diagnosed as Acute pancreatitis, treated at KIMS Narketpally

Not a K/C/O DM, HTN, TB, Asthma, Epilepsy,CVA,CAD

PERSONAL HISTORY:

He is a carpenter by occupation

Diet - mixed

Appetite - normal

Sleep - adequate

Bowel and bladder regular

Addictions: alcohol ( daily 2 quarters ) 

FAMILY HISTORY

No significant family history

TREATMENT HISTORY 

Not significant 

GENERAL EXAMINATION

Patient is conscious , coherent and cooperative. Well oriented to time place and person. Moderately built and nourished 

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema

VITALS:

Pulse - 76 bpm

BP - 110/80 mm Hg

RR - 18 cpm

Temp- 97.8F

SpO2- 98% on room air

GRBS- 124mg%

SYSTEMIC EXAMINATION:

PA:

Inspection:

Shape of abdomen obese 

Umbilicus: Inverted

No visible pulsation,peristalsis, dilated veins and localized swellings.

No scars 

Flanks are normal 

Palpation: 

No local rise of temperature 

tenderness present in epigastric region

Liver not palpable 

Spleen not palpable 

Percussion: 

No fluid thrill, shifting dullness absent

Liver span -12cm 

Auscultation: 

Bowel sounds heard - decreased

CVS:

Inspection:

There are no chest wall abnormalities 

The position of the trachea is central. 

Apical impulse is not observed. 

There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses. 

Palpation:

Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line 

Position of trachea was central 

. 

Auscultation: 

S1 and S2 were heard 

There were no added sounds / murmurs. 

RESPIRATORY SYSTEM:

Bilateral air entry is present 

Normal vesicular breath sounds are heard. 

CNS:

HIGHER MENTAL FUNCTIONS- 

Normal

Memory intact

CRANIAL NERVES :Normal

SENSORY EXAMINATION

Normal sensations felt in all dermatomes

MOTOR EXAMINATION

Normal tone in upper and lower limb

Normal power in upper and lower limb

Normal gait

REFLEXES

Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited

CEREBELLAR FUNCTION

Normal function

No meningeal signs were elicited

INVESTIGATIONS:

8/4/23

Hemogram:

Hb-16.3 gm/dl

TLC-14100 cells/cu.mm

PLT- 2.16 lakhs/cu.mm

RBC- 5.18 million/cu.mm

CUE:

Albumin- +

Pus cells- 3-4

Epithelial cells- 2-3

Blood urea- 36mg/dl

Serum creatinine - 1.0mg/dl

LFT:

TB- 1.17mg/dl

DB- 0.26mg/dl

SGOT- 45IU/L

SGPT- 41IU/L

ALP- 166IU/L

TP- 6.9 gm/dl

Alb- 4.3 gm/dl

A/G- 1.67

Electrolytes

Na-140

K-4.1

CL-102mmol/l

Serum amylase- 841

Serum lipase- 218

FBS-121mg/dl

9/4/23

Hemogram:

Hb: 15.6 gm/dl

TLC: 11,500

Plt: 1.87

RBC: 4.94

Na- 135

K- 3.5

Cl-102

Sr creatinine -0.8 mg/dl

Lipid profile:

Total cholesterol:185

Triglycerides:130

HDL:52

LDL:108

VLDL: 106

10/4/23

Hemogram:

Hb: 16.7 gm/dl

TLC: 10,300

Plt: 1.98

RBC: 5.42

Na 140

K 3.9

Cl 102

Sr creatinine: 0.9

BUN: 29

Total bilirubin: 2.24

Direct bilirubin: 0.42

SGOT: 102

SGPT:138

ALP: 158

US Abdomen 

X-ray 

PROVISIONAL DIAGNOSIS:

Acute Pancreatitis.

TREATMENT:

1.Nill-by-oral  

2.IV FLUIDS 1Unit NS BOLUS @100ml/hr

   2 units NS, RL, 1Unit DNS

3.INJ TRAMADOL 1amp in 100ml NS IV over 1hr/BD

4.INJ THIAMINE 1amp in 100ml NS IV/BD

5.INJ PAN 40mg IV/OD

6.INJ ZOFER 4mg IV/TID

Reference:- Colleague case report