Case of abdominal pain

 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

A 38 year old male who is autodriver  by occupation came to the OPD with the chief complaints of stomach pain since 2 months.

HISTORY OF PRESENT ILLNESS:

Normal routine of the patient:

The patient wakes up by 6AM daily and he used to have his lunch by 1/2 PM (rice & curry ) and returns home by 6.30/7 in the evening. Then he used to have his dinner (rice again) and sleeps by 9 PM.

 The patient was apparently asymptomatic one year back and then he developed stomach pain which was radiating backwards and got subsided on medications given by a local doctor.

He then came to the OPD with the same complaint again.

History of past illness :

The patient is not a known case of diabetes, epilepsy, tuberculosis, asthma, hypertension


Personal history : 

- The patient has loss of appetite

- He takes mixed diet

- No sleep disturbances

- He consumes 100ml(approx)of toddy once in two weeks 

Family history :

- There are no similar complaints in the family members


Treatment history :

- He is not a known case of drug allergy.


General examination :


- Patient is conscious, coherent, cooperative at the time of joining

- No Pallor 

- Icterus present

- No cyanosis

- No clubbing of fingers and toes

- No lymphadenopathy

- No pedal edema






Vitals : temperature - afebrile 


              Pulse rate - 70 bpm


              Respiratory rate - 18 cycles per minute


              BP - 110/70 mm Hg




Systemic examination : 


CVS


Inspection - chest wall is bilaterally symmetrical


- No precordial bulge 

- No visible pulsations, engorged veins, scars, sinuses

Palpation - JVP is normal

Auscultation - S1 and S2 heard



RESPIRATORY SYSTEM


- Position of trachea is central 

- Bilateral air entry is normal

- Normal vesicular breath sounds heard

- No added sounds


PER ABDOMEN 

- abdomen is tender

- bowel and bladder sounds heard

- no palpable mass 

- patient has mild amount of fluid 


CNS

- Patient is conscious

- Speech is present

- Reflexes are normal


Investigations : 











Treatment:

24/11/21

IVF-2NS

     -1DNS 1RL 

INJ THIAMINE 1amp 

INJ PAN 40mg IV

INJ ZOFER 4mg IV

INJ TRAMAD 1amp 

BP/PR/Temp charting 

Monitor vitals 

25-11-21

IVF-2NS

INJ THIAMINE 1amp 

INJ PAN 40mg IV

INJ ZOFER 4mg IV

INJ TRAMAD 1amp 

BP/PR/Temp charting 

Monitor vitals 

27-11-21

IVF-2NS

INJ THIAMINE 1amp 

INJ PAN 40mg IV

INJ ZOFER 4mg IV

INJ TRAMAD 1amp 

BP/PR/Temp charting 

Monitor vitals 

28-11-21

IVF-2NS

INJ THIAMINE 1amp 

INJ PAN 40mg IV

INJ ZOFER 4mg IV

INJ TRAMAD 1amp 

BP/PR/Temp charting 

Monitor vitals 

Questions:

1.what are the causes of acute pancreatitis?

2.why does the pain radiate backwards in pancreatitis?

3.Can ascites occur in pancreatitis if yes,how ?

4.what happens if pancreatitis is left untreated?


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