36 year old male with epigastric pain.

 

36 year old male with epigastric pain

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Case History

CHIEF COMPLAINTS -

A 36 year old male , driver by occupation ,came to the casualty with cheif complaints of


-Pain in the epigastric region since 9 days 


HISTORY OF PRESENTING ILLNESS -


Patient was apparently asymptomatic 9 days back 

h/o complains of epigastric pain on 1st of janunary

Type- Continuous,dragging type of pain

Non radiating.

Onset - sudden

Duration - since 9 days

Aggrevated by sleeping in lateral position.

Relieved on medications.

Associated with abdominal tightness since 4 days.

then he developed fever- high grade 

sudden in onset, associated with chills and rigors and headache (frontal and occipital) c/o sob since 5 days (grade 2 )    complains , history of   back pain since 4 days , and constipation since 4 days  and decrease in appetite. 


complains of belching 2 to 3 times per day 

He had similar episode previously in June 2021 with complaint of pain and distended abdomen. 

no history of nausea, vomiting , no h/o loose stool ,no history of past surgery 
no history of jaundice previously 
no history of gallstones, 


PAST HISTORY - 

Similar history 6months back , not a known case of htn , dm , epilepsy , asthma , tb
no previous surgical history 
no history of gallstones in the past


PERSONAL HISTORY :


Diet - mixed 

Appetite -decrease appetite ,

Bowel movement - irregular since 3 days, bladder movements - regular , Addictions(alcohol and smoking) - 
alcoholics in seven years takes at least 150 ml 
occasional toddy user also since six months drinks 180 ml per day 
no history of smoking or chewing tobacco
 brand used it is (royal stag or ib )180 ml per day is in six months


FAMILY HISTORY - 

not significant


GENERAL EXAMINATION -


Patient is concious , coherent ,cooperative ,well oriented to time ,place and person.
no pallor , icterus- present , clubbing , cyanosis , lymphadenopathy , edema



vitals - 
On ,8-1-22

temperature - afebrile

pulse rate - 97 bpm

blood pressure - 100 /70 mm of hg 

respiratory rate - 22

spo2 - 98% at room air


SYSTEMIC EXAMINATION - 


cardiovascular system : s1 and s2 heard , no murmurs
respiratory system : bilateral air entry present ,normal vesicular breath sounds
central nervous system : nad

p/a -
Abdomen is slightly distended, soft.

Umbilicus - normal(central ,inverted)

All quadrants moving appropriatly on respiration.
pain in the epigastric region and 

pain is more in the right iliac and lumbar region

No scars , engorged veins, visible peristalsis.
no bruit’s , no gaurding, no rigidity
negative cullens sign and grey turners sign, no fox's sign
bowel sounds present 

No organomegaly

Shifting dullness - absent.

On 9-1-22


INVESTIGATION - 

ECG:

HEMOGRAM: 




CUE:



RFT:



Serum amylase - 223 u/l

Serum lipase - 86.1 u/l

Colour doppler 2D Echo:

Ultrasound abdomen:

CT scan

COMPLETE URINE EXAMINATION: 

PROVISIONAL DIAGNOSIS -

Acute pancreatitis
With alcohol dependence

TREATMENT GIVEN -

1 . ivf ns and rl and dns @ 50 ml /hr

2. ink . pantop 40 mg iv/od

3 .ink zofer 4 mg iv sos

4. inj tramadol 1 amp in 100 ml na iv bd

5.inj buscopan 22 cc iv/sos

6.tab pcm 650 mg po/tid 

7.grbs 6 th hourly

8 temp and i/o charting

-Ryles tube aspiration- continuous

-Prophylactic enema

Questions
What are the cause of his basal atelectasis and pleural effusions?.