A 50 YEAR OLD MALE WITH PAIN ABDOMEN IN EPIGASTRIUM
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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.
CASE:
A 50 year old male patient came to the casualty complaining of pain abdomen in epigastrium
DAILY ROUTINE:
Patient By ocvupation he is carpenter and lorry driver ,He used wake up at 6am im morning and goes for walking till 6.30am.Then takes his breakfast and start doing his regular wood work in between around after he used take 90 to 120 ml of alchol with his freind irregularly the he had his lunch.He continues his work till evening and daily he used have 150ml of alcohol before going bed to get his sleep without any disturbences.He was doing this activities since last 10 yrs.
1 year ago got pain in abdomen and diagnosed as acute pancreatitis and treated,after this episode he stoped drinking alcohol for 2 months and then again started drinking daily in the evening around 90ml regularly
History of presenting illness:
Patient was apparently asymptomatic 1 day back then he developed Pain Abdomen in epigastrium which is insidious in onset and gradually progressive.
No complaints of vomitings, loose stools, fever, SOB, chest pain, palpitations, orthopnea,PND.
Past history:
History of similar complaints in the past.
Not a known case of Hypertension, DM, asthma,epilepsy, CAD, thyroid disorders, TB
Personal history:
Diet-mixed
Appetite-normal
Sleep-adequate
Bowel and bladder movements-regular
Addictions- alcohol intake since 20 years
Family history:
Not significant
General examination:
Patient was consious, coherrent and co-operative. Well oriented to time place and person.moderately built and nourished
pallor -present
No icterus
No clubbing
No cynosis
No generalized lymphadenopathy
No b/L pedal edema
Vitals:
Temp: 98.7F
PR- 79 bpm
RR-20cpm
BP-160/90 mm of Hg
Spo2 -98%
GRBS:200mg/dl
RS-B/L air entry present, NVBS
CVS- S1S2present, no murmurs heard
PA- tenderness present in epigastrium
CNS- HMF + No FND
INVESTIGATION
6/7/2023
DIAGNOSIS:
? Acute on Chronic pancreatitis
? Alcoholic gastritis
with K/c/o HTN and DM Type 2 since 2 years
TREATMENT:
1.inj.TRAMODOL 1 amp in 100 ml NS 1g IV/BD
2.IVF NS 100ml/hour
3.tab.METFORMIN 500 mg at 8 am
4.tab.TELMASARTAN 40 mg PO/OD at 9am
5.Inj. Zofer 4 mg IV/OD at 7 am
6.monitor vitals 4th hourly and inform sos
B.P CHARTING
GRBS CHARTING
