45year old male with constipation,pain abdomen,vomitings















This is a case of a 45 year old male, carpenter by occupation came to OPD with chief complaints of

1. Constipation since 3 days

2. Pain in abdomen since 2days

3. Vomitings since 2 days.


HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 2 days ago then he developed pain in the abdomen- in epigastric region.

It was sudden in onset, gradually progressive.

Pain more after eating food and on lying in supine position.

Pain relieved on sitting , on bending forward.

-H/O 3 episodes of Vomiting yesterday after eating food, food as content, non bilious, non projectile, not blood tinged.

-Constipation since 3 days


No H/O fever, cough, cold, shortness of breath, loose stools, giddiness.

Last binge of alcohol consumption 2days ago.




PAST HISTORY:

H/O similar complaints 2 years ago- diagnosed as Acute pancreatitis, treated at KIMS Narketpally

Not a K/C/O DM, HTN, TB, Asthma, Epilepsy,CVA,CAD




PERSONAL HISTORY:

He is a carpenter by occupation

Diet - mixed

Appetite - normal

Sleep - adequate

Bowel and bladder regular

Consumes 2quarters of alcohol/day.


FAMILY HISTORY

No significant family history




GENERAL EXAMINATION

Patient is conscious , coherent and cooperative. Well oriented to time place and person. 

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema

VITALS:

Pulse - 76 bpm

BP - 110/80 mm Hg

RR - 18 cpm

Temp- 97.8F

SpO2- 98% on room air

GRBS- 124mg%



SYSTEMIC EXAMINATION




PA:

Inspection:


Round, large with no distention

Umbilicus: Inverted

No visible pulsation,peristalsis, dilated veins and localized swellings.


Palpation: 


Soft, tenderness present in epigastric region

No signs of organomegally


Percussion: 


No fluid thrill, shifting dullness absent


Auscultation: 

Bowel sounds heard 2-3/ minute


CVS:


Inspection:


There are no chest wall abnormalities 

The position of the trachea is central. 

Apical impulse is not observed. 

There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses. 


Palpation:


Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line 

Position of trachea was central 

. 


Auscultation: 


S1 and S2 were heard 

There were no added sounds / murmurs. 


RESPIRATORY SYSTEM:


Bilateral air entry is present 

Normal vesicular breath sounds are heard. 


CNS:


HIGHER MENTAL FUNCTIONS- 


Normal

Memory intact


CRANIAL NERVES :Normal


SENSORY EXAMINATION


Normal sensations felt in all dermatomes


MOTOR EXAMINATION


Normal tone in upper and lower limb

Normal power in upper and lower limb

Normal gait


REFLEXES


Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited



CEREBELLAR FUNCTION


Normal function


No meningeal signs were elicited




INVESTIGATIONS:



8/4/23

Hemogram:

Hb-16.3 gm/dl

TLC-14100 cells/cu.mm

PLT- 2.16 lakhs/cu.mm

RBC- 5.18 million/cu.mm


CUE:

Albumin- +

Pus cells- 3-4

Epithelial cells- 2-3


Blood urea- 36mg/dl

Serum creatinine - 1.0mg/dl


LFT:

TB- 1.17mg/dl

DB- 0.26mg/dl

SGOT- 45IU/L

SGPT- 41IU/L

ALP- 166IU/L

TP- 6.9 gm/dl

Alb- 4.3 gm/dl

A/G- 1.67


Electrolytes

Na-140

K-4.1

CL-102mmol/l


Serum amylase- 841

Serum lipase- 218

FBS-121mg/dl








PROVISIONAL DIAGNOSIS:

Acute Pancreatitis.


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