67 Yr Old Man presenting with Abdominal Pain

E LOG GENERAL MEDICINE








Hi, I am Rishitha, 5th 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!

CASE SHEET


A 67 year old male, resident from lingotum presented to the GM OPD with the chief complaints of abdominal pain


CHIEF COMPLAINTS

Pain in the epigastrium since 5 days

Burning micturition since 5 days  


HOPI

Patient was apparently asymptomatic 5 days back which when he developed pain in the abdomen.  

Pain was insidious in onset gradually progressive, dragging type of pain, aggrevating during night. 

Pain radiating to the back, and relieving on leaning forward  

Burning micturition since 5 days.

No h/o vomiting

No h/o constipation  


PAST HISTORY

known case of  diabetes since 1 week  

Not a known case of HTN, Seizures, TB 


TREATMENT HISTORY: not significant

FAMILY HISTORY: not significant  


PERSONAL HISTORY

Apetite: decreased 

Bowel bladder: burning micturition 

Sleep: disturbed 

History of consumption of alcohol since 10 years


DAILY ROUTINE

Patient wakes up at 6 am in the morning and freshens up and goes for a walk and has a cup of tea later. He then goes for farming and has his lunch at around 2pm. He comes back home by 5pm in the evening and has his tea biscuits and finishes his dinner by 9 pm and goes to sleep. 

He consumes alcohol on alternate days, of quantity 90ml (100rs). He has started drinking to overcome tiredness and fatigue at the end of the day, and continues to do so until 5 days back when he had this acute exacerbation of pain on alcohol consumption. He aspires to stop drinking. 


GENERAL EXAMINATION

No signs of pallor, cyanosis, clubbing, lymphadenopathy

Icterus present 


VITALS 

Temp- 98.3

Blood pressure- 130/80

Pulse Rate - 69 bpm

Sp02- 98%


SYSTEMIC EXAMINATION

CVS:S1 and S2 heard no murmurs

Respiratory system:
Bilateral equal chest expansions
Trachea central
Bilateral air entry present
Expiratory ronchi heard on in all lung fields

CNS: 
Normal
No focal neurological deficits

Abdomen: 

Inspection: 
Shape: Scaphoid
Normal hernial orifices
No scars 
No sinuses 
No venous engorgement

Palpation: 
All inspectory findings confirmed. 
No local rise of temperature. 
Tenderness : present in all quadrants
No free fluid
Liver and  spleen not palpable





INVESTIGATIONS 

1. Complete Blood Picture 
2. Urine Analysis
3. Liver Function Tests 
4. Serum Amylase
5. Serum Lipase
6. ECG
7. 2D Echo








 





PROVISIONAL DIAGNOSIS

Acute on Chronic Pancreatitis


TREATMENT 

Nothing by mouth 
Inj. Ceftriaxone 
Inj. Tramadol 
Inj. Pantop
Inj. Zofer 
Inj. Thiamine 















 

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