This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.
CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDER
Chief complaints:
A 50 year old man, resident of Nalgonda came to OPD on 16/3/23 morning with chief complaints of pain abdomen since 6hrs.
History of presenting illness:
He developed pain abdomen at 12 am on 15/3/23 which was sudden in onset and gradually progressive. Pain was diffusely present but more in umbilical and left lumbar region. It was colicky type and non radiating. Pain was continuous with no aggravating and relieving factors.
History of alcohol intake present.
No history of fever,nausea,vomiting or loose stools.
Past history:
Similar complaints in the past 2 years back and was diagnosed to have acute pancreatitis.
He is a known case of diabetes since 2 years and was on medication(?)
No history of Hypertension, Asthma,Tuberculosis, CAD.
Personal history:
Daily routine:
He wakes up at 8 am and does his daily routine and is not working ,takes 3 meals daily and drinks alcohol and smokes intermittently through the day and sleeps by 10 pm.
Diet- mixed
Appetite- normal
Bowel and bladder movements- regular
Sleep- disturbed since 2 days
Addictions- chronic alcoholic since 30 years(takes about 180 ml per day on average)
Smokes cigarettes 2-3 packs per day since 30 years
Family history:insignificant
General examination:
Patient is conscious,coherent and cooperative ,moderately built and nourished.
Pallor:absent
Icterus:absent
Cyanosis:absent
Clubbing:present
Lymphadenopathy:absent
Edema:absent
Vitals:
Blood pressure: 150/100 mm Hg
Pulse rate:65bpm
Respiratory rate:20 com
Temperature:afebrile
Systemic examination:
Per abdomen examination:
On inspection: abdomen is obese,umbilicus is central and inverted. All quadrants of abdomen are moving accordingly with respiration. No visible scars,sinuses,engorged veins.
On palpation: all inspectory findings are confirmed, abdomen is soft and tenderness is present in the umbilical and left lumbar lumbar region. No guarding or rigidity . No hepatospleenomegaly and hernial orifices are free.
On percussion: no shifting dullness
On auscultation: bowel sounds heard
CVS: S1,S2 heard,no murmurs
Respiratory system: bilateral air entry present,normal vesicular breath sounds heard
CNS: no neurological deficit.
Provisional diagnosis:
Acute on chronic pancreatitis secondary to alcohol intake.
Investigations:
Hemogram:
Hb 16.2 mg/dl
Total count 9,300 cells/cumm
Neutrophils 82%
Lymphocytes 10 %
MCV 91.9
MCH 32.5
MCHC 35.5
RBC count 4.96 millions/cumm
Smear:
Normocytic,normochromic-RBC
WBC within normal limits with neutrophils
Platelets- adequate
Serum Lipase: 230 IU/L
Serum Amylase: 471 IU/L
RBS: 246 mg/dl
LFT:
Total bilirubin :1.25 mg/dl
Direct bilirubin 0.52 mg/dl
SGOT: 32 IU/L
SGPT: 41 IU/L
Alkaline phosphatase : 322 IU/L
Total proteins 7.7 gm/ dl
Albumin : 4.45 gm/dl
CUE:
Pale yellow,clear,acidic
Sp gravity: 1.010
Albumin ++
Sugar +
Bile salts nil
Bile pigments nil
Pus cells 4-5 /HPF
RBC nil
USG:
Grade I fatty liver
CT:
Pancreas:
Bulky with heterogeneous parenchymal enhancement with peripancreatic fat stranding associated with fluid traversing along left paracolic gutter.
No parenchymal necrosis.
No peripancreatic collection or pseudo cyst
Splenic artery patent
Minimal ascites.
Spleen normal
Liver ,gall bladder normal
Impression: features suggestive of acute interstitial pancreatitis with modified CT severity score of 4. Minimal ascites
Treatment:
-NBM
- IV fluids : NS and RL ( 100ml/hr)
-Inj pantop 40mg IV OD
-Inj Thiamine 200mg in 100ml NS iv tid
- Inj HAI s/c tid premeal.
- BP, PR, RR, temperature monitoring and charting 4th hourly.
