general medicine case presentation

40 yr old male patient who is daily wage labourer by occupation came to OPD with

Chief complaint

of pain abdomen since 5 days associated with fever since 2 days 

HOPI

Patient was apparently asymptomatic 5 days ago then he developed pain which is insidious in onset and gradually progressive which is diffuse , squeezing type and radiating to back .

Pain is relieved on medication .

No C/O of vomitings , loose stools , burning micturition ,cough,cold , chest pain , SOB 

Past history:-

N/K/C/O TB , hypertension, diabetes, Asthma, epilepsy , CAD, thyroid disorders .

Personal hisrory:-

Diet - mixed 

Appetite- normal

Bowel and bladder -regular

Sleep - adequate

Addictions - regular alcohol intake of 250 ml per day since 20 yrs .

No food allergies and drug allergies

General examination:-

Pallor - yes 

Edema -absent 

Clubbing - absent 

Lymphadenopathy - absent 

Icterus - absent 

Cyanosis absent

 Vitals:-

Temperature - 100.1F

BP-85/60

Spo2- 98%

RR-20pm

PR- 100/min

Systemic examination:-

Per abdomen examination

Patient exposed from nipple to mid thigh and examined in supine position 

INSPECTION: 

• Shape:Distended flanks full 

• Umbilicus:inverted,vertically drawn down

• Skin over the abdomen is shiny

• No visible peristalsis,

• Palpation:

  On superficial Palpation 

  • All inspectory findings are confirmed 

  • Tenderness+

  • ,diffuse all quadrants

  • No Rebound tenderness 

• No guarding,rigidity

  Percussion

  Shifting dullness  absent 

  fluid thrill absent 

  Liver span-12cm

  Percussion of spleen : dullness in 9th inter coastal space of anterior axillary line 

  Auscultation 

  Bowel sounds+

  No arterial bruit,

  RESPIRATORY SYSTEM 

  Inspection 

  • Shape of chest:Bilaterally symmetrical,Elliptical in shape

  • No visible chest deformities

  • Abdomino thoracic respiration,No irregular respiration

  • No tracheal shift

  • No dropping of shoulders, on both sides,no sinuses,scars,engorged veins

  Palpation:inspectory findings confirmed by Palpation 

  • Chest movements -normal

Percussion:

Resonant note heard over all areas 

Auscultation: 

Norma vesicular breath sounds

, breath sounds normal 

Cardiovascular system:

Inspection:precordium normal,apex beat :5th ICS half inch medial to mid clavicular line

Palpation:inspectory findings confirmed,No thrills or parasternal heave

Auscultation: S1S2+,no murmurs

CNS:

patient is arousable 

No signs of meningitis 

cranial nerves intact,motor and sensory examination normal

No cerebellar or meningeal signs

Reflexes:




Reflexes          Rt.      Lt 


Knee                3+.      3+

Biceps               3+.    3+

Triceps              3+.    3+

Supinator          2+.    2+

Knee                  3+.     3+




              Right.        Left 


UL.        2/5.           3/5

LL.          2/5.         3/5




provisional diagnosis :-
• Acute pancreatitis ( non necrotizing type) peripancreatic fluid collection.
  
  
  Investigations:
  
  
  
  
  
  
  
  
  
  Treatment:-

  1 .IV fluids 125ml/hr 

  2.injec.zoffer 4 mg IV

  3.inj Tramadol 1 ampoul in 100ml NS

  4.inj piptaz 4 to 5 mg 

  5. Inj pan 40 mg IV

  6.inj neomol 1gm IV