30 yr old male

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Name: CH. Preethi

Roll no: 19

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 a diagnosis and treatment plan.

Following is the view of my case :

CASE PRESENTATION:

A 30 year old male who is a resident of kotamarthy village bhongiri district, painter by occupation has come to the OPD with the chief complaints of 

• Pain in the epigastrium since 2 days
• Vomitings since 2 days

History of Presenting illness:

Patient was apparently asymptomatic 2 days ago then he developed pain in the epigastric region after consuming alcohol. It was sudden in onset, increasing in intensity and is of sequezing type. Pain is persistent throughout the day. Aggrevated with food intake and is relieved on taking medication.

Since 2 days patient had 7-10 episodes of vomitings, non projectile and is non bilious and is blood stained

Food particles as contents

H/O alcohol binge 2 days back

No history of fever, giddiness

Past history:

• Similar episodes had occured 7-8 times in the past 4 years following continuous drinking of alcohol.
•  Last episode was one month back presented with complaints of pain abdomen- epigastric region also 4-5 episodes of vomitings with food particles mixed with blood and there suspected as upper GI bleed secondary to peptic ulcer. Advised endoscopy but patient didn't get it done.
• Whenever the situation recurrs, he was treated with fluids and analgesics and was advised to cut down on drinking
• Not a known case of hypertension, diabetes, asthma, tuberculosis
• No history of gall stones
• No history of blood transfusions
• No history of any previous surgeries
• Personal history:
• Diet- Mixed
• Appetite- Decreased
• Sleep- Adequate
• Bowel and bladder movements- Regular
• Addictions- 
• Alcohol consumption since the age of 12 yrs. Consumes 180 ml almost everyday
• Tobacco chewing- since 6 years(1 pack- 2 to 3 times a week)

Allergic history:

No history of known allergies

Family history:

No significant family history

His mother is hypertensive since 10 years and is on regular medication

No family history of Diabetes, Asthma, TB, Epilepsy

General Physical Examination:

Done after obtaining consent, in a well-lit room, in the presence of an attendant, with adequate exposure. 

The patient is conscious, coherent, cooperative, well oriented to time, place, person.

Well nourished and moderately built

Pallor- Absent

Icterus- Absent

Cyanosis- Absent

Clubbing- Absent

Lymphadenopathy- Absent

Edema- Absent

Vitals:

Temperature- Afebrile

Pulse rate- 80bpm

Respiratory rate- 16cpm

Blood pressure- 110/70 mm/Hg

SPO2- 98%

SYSTEMIC EXAMINATION:

1. CVS: S1 & S2 heard

2. Respiratory system: bilateral air entry present, normal vesicular breath sounds

3. CNS: no focal deficit

4. Abdomen: 

On inspection abdomen is scaphoid, the umbilicus is inverted. No visible peristalsis, pulsations, engorged veins and no hernial sites. Negative cullen's sign, grey turner's sign, fox's sign

Palpation: Inspectory findings confirmed. There is tenderness in the epigastric region. No guarding and rigidity.

Percussion: Tympanic sounds are heard

Auscultation: No bowel sounds are heard.No bruits

INVESTIGATIONS:

Hemogram:

Hb- 15.3

TLC- 7500

Platelets- 1.5 lakh

Renal function tests:

Urea- 25 mg/dL

Creatinine- 0.9 mg/dL

Serum electrolytes:

Sodium- 140 mEq/L

Potassium- 4.0 mEq/L

Chloride- 98 mEq/L

Liver function tests:

Total bilirubin- 3.56

Direct bilirubin- 0.98

AST/ALT- 26/10

ALP- 127

TP- 6.3

Albumin- 3.7

Serum amylase- 32

Serum lipase- 24

Random blood sugar- 90

ECG:

USG:

Psychiatry referral:

He was sent for psychiatric referral to evaluate for alcohol dependence.

He was also diagnosed with alcohol dependence syndrome.

Provisional diagnosis:

Chronic pancreatitis with upper GI bleed secondary to peptic ulcer disease?

Treatment:

Intra venous fluids NS and RL- 100 ml/hour

Inj. PAN 40 mg IV/OD

Inj. ZOFER 4 mg IV/TID

Inj. Thiamine 1 amp in 100 ml NS IV/OD

Inj. Tramadol 1 amp in 100 ml NS IV/TID

BP/PR/Temperature monitoring- 4th hourly

GRBS monitoring 12th hourly