50 yr old male with Acute Pain Abdomen and Vomitings

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I have 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 diagnosis and treatment plan.

Rollno.61- Aruna.J

A 50YR old male patient with Chief complaints of Pain Abdomen more in the epigastric region and vomitings.

HOPI: Patient complained of Pain abdomen more in the epigastric region which was dull aching type radiating to the back,  on taking spicy food or alcohol it remains as a dull diffuse type all over the abdomen aggravated on movement, with no releiving factors. 2 to 3 episodes in a month and associated with vomiting non bilious,non projectile,watery and light yellowish in color . 

H/O - Constipation,nausea.

No H/O Fever,weight loss,changes in color of urine or stool,fatigue,Anorexia,cough,shortness of breath,dysuria,hematuria.

PAST HISTORY: 

He is a known case of Hypertension since 5years on medication-Tab.Angiosart(40mg/day)

No H/O -DM,T.B,Epilepsy,Asthma,CAD.

PERSONAL HISTORY:

Diet- Mixed

Appetite- Reduced

Bowel and Bladder -

Constipated-bowel movements once in 2 days.

Sleep- Disturbed and Inadequate

Addictions- Consumes Alcohol everyday f(50-80ml) smoking (3 cig/day) since past 15years.

FAMILY HISTORY-Nothing significant

Drug History-No known drug allergies

The patient used to take Antacids to get releived from pain abdomen.

ON EXAMINATION

Patient was conscious, coherent, co operative.

GENERAL PHYSICAL EXAMINATION

Pallor-absent 

#Icterus- Present

Cyanosis- absent

Clubbing- absent

Generalized lymphadenopathy- absent

**Vitals**

Temperature- Afebrile

Pulse rate -80bpm

Respiratory Rate - 18cpm

Blood pressure-138/90mmHg

sPo2 97% at room temperature

SYSTEMIC EXAMINATION

CVS: Inspection

Chest wall is bilaterally symmetrical.

No precordial bulge is seen 

Palpation

JVP- Normal

Apex beat -felt in the left 5th intercoastal space in the mid clavicular line 

Auscaltation-

S1&S2 are heard,no murmur found.

RESPIRATORY SYSTEM

Position of trachea- central

Bilateral air entry, normal vesicular breath sounds are heard.

No added sounds

CVS

Patient is conscious ,coherent and co operative , well oriented to time and space.

Speech normal.

No signs of meningeal irritation.

Motor and sensory system- Normal

Reflexes - present

Cranial nerves - intact

PER ABDOMEN

On inspection:

#Abdominal distention - present

All quadrants are moving equally with respiration

Umbilicus - central and inverted

No scars,dilated veins, prominent Venous pulsations and visible pulsations.

On palpation::

Superficial palpation- No Local rise in temperature and no tenderness

Deep palpation- pain felt , No guarding, rigidity

On percussion::

Tympanic note - heard 

No shifting dullness

On auscaltation::

Bowel sounds heard 

PROVISIONAL DIAGNOSIS: Acute Pancreatitis secondary to Alcohol intake .

INVESTIGATIONS-

TREATMENT:

1.Fluid and Salt restriction.

2.Inj.LASIX 40mg/I.V/BD

3.TAB.HYDRALAZINE 12.5mg/PO/OD

4.TAB.NICARDIA XL 3mg/PO/OD

5.TAB.BISOPROLOL 5mg PO/OD

6.TAB.ECOSPRIN AV75 /20mg/PO/OD

7.TAB.NODOSIS 500mg PO/TD

8.Intermittent NIV

9.Inj.CLIMDAMYCIN 600mg/I.V/BD

10.Inj.MEROPENAM 500mg/I.V/BD