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