Case of a 36 yr old male with Acute Pancreatitis with Alcohol Dependence Syndrome
This is an E logbook to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here, we discuss our individual patient's problems through series of inputs from an available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence-based inputs. This E-logbook also reflects my patient-centered online portfolio and your valuable inputs in the comments are 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 a diagnosis and treatment plan.
CASE PRESENTATION:
A 36 year old driver by occupation came to the OPD with :
CHIEF COMPLAINT:
Pain in the epigastric region since 9 days
HISTORY OF PRESENTING ILLNESS:
The patient was apparently asymptomatic 9 days back then he developed pain in the epigastric region which was sudden in onset, gradually progressive,dragging type, non-radiating , aggrevated on sleeping in lateral position relieved on taking medications.
Patient complains of abdominal tightness and belching (2-3times/ day)
Not associated with nausea, vomitings.
On 31st he consumed alcohol heavily,next morning he had severe epigastric pain. He went to a private hospital for treatment. He was given medications.
Then he came to the present hospital.
He had fever with chills and rigor, SOB ( grade 2) and constipation when he presented to the hospital.
PAST HISTORY:
Patient had similar complains 6 months back .
Not a K/C/O Hypertension, Diabetes, asthma, CVD, TB.
No history of previous surgery
No H/O gall stones
PERSONAL HISTORY:
Diet: Mixed
Appetite: Decreased
Sleep: Adequate
Bowel and bladder : Regular
Addictions:
Alcohol consumption since 7 years (150 ml/ alternate day)
Since 6 months 180ml/day ( Royal Stag)
Occasional toddy drinker
No smoking or tobacco chewing
FAMILY HISTORY : Insignificant
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative and well- oriented to time, place and person.
Patient was examined after obtaining a signed informed consent.
No pallor, icterus, cyanosis, clubbing, edema, lymphadenopathy.
Vitals:
Temperature: Afebrile
BP: 100/70 mmHg
Pulse rate: 97bpm
Respiratory Rate: 22cpm
SpO2: 98% on room air
SYSTEMIC EXAMINATION:
CVS: S1 S2 heard, no murmurs
RS: BAE +, NVBS heard
CNS : NAD
PER ABDOMEN:
Inspection : Abdomen is slightly distended
Position of umbilicus : Normal
No visible pulsations, visible peristalsis
No striae, scars
Palpation :
No local rise of temperature
Tenderness in the epigastric region
No guarding and rigidity
Cullen's sign, Grey Turner's sign and Fox's sign: Negative
Liver, spleen - Not palpable
Percussion : Resonant note heard
No shifting dullness / fluid thrill elicited
Auscultation : Bowel sounds heard
LAB INVESTIGATIONS :
HEMOGRAM:
RENAL FUNCTION TEST:
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