28 YEAR OLD MALE PRESENTING WITH PAIN IN ABDOMEN AND VOMITING.

E- LOG GENERAL MEDICINE


Hi, I am Rishitha, 3rd Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING!


* This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.

*Elog made under guidance of Dr. Swaroopa (Intern)


CASE SHEET


 28 YEAR OLD MALE PRESENTING WITH PAIN IN ABDOMEN AND VOMITING.


A 28 year old male who is alcoholic and smoker since 18 years came with the chief complaints of pain abdomen and vomiting since 2 days.


Cheif complaints

  • Abdomen pain and vomitings from 2 days
  • Constipation from two days


History of present illness 

  • Patient was apparently asymptomatic 3 days back.
  • And then he had a binge of alcohol and went to a local Ayurvedic doctor for alcohol Deaddiction , where he was given some herbal medicine. 
  • Following which he had Diffuse Abdominal Pain (more in epigastric region) and vomitings.
  • Bilious, Non projectile vomitings associated with food intake. 
  • No H/o firm or loose stools.
  • Constipation from 2 days. 


History of past illness

  • Not a known k/c/o DM, HTN, Thyroid, Asthma, Epilepsy, CAD. 
  • H/o similar complaint in past 2018-2019 and Jan 2021


Family history 

  • No relevant family history 

Personal History 

  • Diet- Mixed
  • Appetite- Decreased 
  • Bowels- Constipated (from 2 days)
  • Micturition- Abnormal (decreased  U.O)
  • No allergies 
  • Regular consumer of alcohol from past 10 years, 360 ml daily.

  • Regular consumer of smoking tobacco from past 10 years, 4-5 cigarettes daily. 


Treatment History 
  • Surgery- Appendectomy, 20 years back. 


Physical Examination 

Pallor: - Not seen.

Icterus: - Not seen

Cyanosis - Not seen

Clubbing - Not seen

Lymphadenopathy - Not seen

Edema of foot - Not seen

Dehydration - Not seen.


Vitals

Temperature - 98.6 °F

Pulse rate - 82/ min

RR - 18/ min

BP - 170/90 mm/Hg

SpO2 - 98%


Systemic Examination 

1. CVS

  • No thrills
  • S1 and S2 heard
  • No murmers


2. RESPIRATORY SYSTEM 

  • No dyspnoea
  • No wheezing
  • Position of trachea - central 
  • Vesicular breath sounds heard
  • No adventitious sounds


3. ABDOMEN

  • Shape - Scaphoid
  • Tenderness present in Epigastrium and L. Hypochondrium
  • No palpable mass
  • Normal hernial orifices
  • No free fluid 
  • No Bruits 
  • Liver is not palpable
  • Spleen is not palpable


4. CNS

  • Patient is Conscious and Coherent 
  • Normal Speech
  • No signs of meningeal irritation 
  • Cranial Nerves intact
  • Motor system reflexes are normal 
  • Glasgow scale - 15/15
  • Normal Gait


Provisional Diagnosis :- Recurrent Pancreatitis 2° to Alcohol 



Investigations that were ordered for given patient 

1. CXR




2. Serum Electrolytes




3. Serum Creatinine 




4. ECG





5. Blood Urea





6. LFT




Ongoing Clinical features. 

Day 1.

  • Patient has no complaints

Day 2.
  • Chief complaint- vomitings associated with food intake.
  • So patient was on NBM and Ng tube was inserted for aspiration and feeding purposes.
  • The aspirated fluid was blue in colour.
Day 3.
  • No other complaints
  • Pt on NBM





















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