Acute on chronic pancreatitis
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K.shirisha
Rollno;60,
9th semester
I’ve 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
( All the information have been collabated from patient).
Case discussion;
Following is the view of my case
40 year old male patient , occupation by field visiter and cable operator came to the casuality on 3/3/22.
Chief complaints;
Abdominal pain since 1 day
Vomitings since 1 day
History of present illness;
The patient was apparently asymptomatic 1 day ago then he developed a abdominal pain which was sudden in onset gradually progressive in nature . which was squeezing and dragging type. No aggrevating and relieving factors. Non radiating .
* Vomitings with episodes of 15- 20 times ina day which was non bilious containing food as particles,non projectile.
* Decreased appetite .
He is a chronic alcoholic since 25 years he drinks 180-360 ml( whisky) / day
Since 3 days he consumed 360 ml alcohol daily .
No history of fever,loose stools, constipation, shortness of breath, cough.
Past history; he had similar complaints in the past( 3 years ago) and diagnosed as acute pancreatitis and treated here for 1 week.
He is known case of diabetes since 15 years ago . He had giddiness so he went to local hospital thre sugar test was done and diagnosed bas diabetes .he was on oral hyperglycemic drugs .of irregular medication.
1 year ago he was on Humanactropid (HAI) 10 U in morning and 5 U in evening.
After 5 years he had again giddiness and headche due to financial issues and work . He again visited local hospital and his blood pressure was checked and diagnosed as a hypertension. He was on tab.amlodipine 5mg od.
Personal history :
Appetite ; decreased
Diet: mixed
Bowel and bladder : regular
Sleep: adequate
Addictions; chronic alcoholic since 25 years
General examination;
The patient is conscious coherent and cooperative and moderately built and nourished
Pallor : absent
Icterus : absent
Cyanosis : absent
Clubbing : absent
Edema : absent
Lymphadenopathy : no generalized lymphadenopathy
Vitals;
Temperature : afebrile
Heart rate. : 86bpm
Blood pressure; 180/110mmHg
Respiratory rate; 20 cpm
GRBS ; 397mg/dl
Spo2 ; 99@room air
Systemic examination ;
Right eye
Per abdomen
Inspection ;
Shape ; normal
Umbilicus : central
Movements equal on respiration
No visible pulsations, engorged veins,no visible peristalsis
Skin over abdomen ; normal
Palpation;
Tenderness in left hypochondrium, epigastrium and left iliac fossa which was diffused
No organomegaly
Percussion; resonant note heared
Auscultation : bowel sounds were heared
Respiratory system ;
Inspection ;
Inspection of upper respiratory tract;
Oral cavity ; normal
Nose: no dns,polyp
Pharynx; normal
Lower respiratory tract;
Position of apex beat ; left 5ics 1cm medial to mid clavicular line
Symmetry of chest : symmetrical and elliptical
Movements of chest ; normal
Position of trachea ; midline
Bilateral air entry present
Palpation:
No tenderness over chest wall,no crepitations,no palpable added sounds,no palpable pleural rub
Percussion;
Resonant note heared
Auscultation; normal vesicular breath sounds heared, bilateral air entry present
Cardiovascular system;
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