Gm final practical long case
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Date of admission : 7/02/2022
CHIEF COMPLAINTS:
A 27 year old male patient electrian by occupation presented to OPD with chief complaints of pain in stomach and Vomtings since 3 months
HISTORY OF PRESENT ILLNESS:
patient was apparently a symptomatic 3 months back, then he had a trauma where his relatives has beaten him with stick at the left hypochondrium region and then he developed abdominal pain associated with vomiting then the pain subsided on taking medications
After a few days he again developed pain abdomen at the left hypochondrium region and the pain radiating to back ,he went to hospital where he under went treatment but the symptoms didn't subsided
So he went to other hospital where he took treatment..he was tested covid positive in the middle of the treatment ,so he went to home isolation .
After few days he underwent the treatment after testing covid negative, the symptoms were subsided then.
Then after he again developed the pain since 3 days before he was presented to our hospital with c/o of abdominal pain(hypochondrium region) which is radiating to his back.
The pain is aggrevated with walking, sleeping after a prolonged duration of sitting and relieved when he bends forward.
Patient complaints pain after eating.
PAST HISTORY :-
No history of-
diabetes/hypertension/asthma/epilepsy
No previous surgical history
PERSONAL HISTORY
Diet : mixed
Appetite : decreased since 10 days
Sleep : inadequate
Bowel & bladder : irregular since 3 days
addictions :- history of alcohol intake since 4 years consumes 360ml per day, he stopped consuming since 4months
Regular usage of khaini since 4 years.
FAMILY HISTORY :
No relevant history
GENERAL EXAMINATION :
Patient is conscious, coherent, cooperative and thin built
pallor , Icterus,clubbing, cyanosis ,edema are absent
VITALS :
Temp- Afebrile
Bp-100/80 mm hg
Pr- 84bpm
Rr-16cpm
Spo2- 99% on RA
Grbs : 102
SYSTEMIC EXAMINATION :
Respiratory system- bilateral air present
No dyspnea
No wheeze
Position of trachea- central
ABDOMEN-
Tenderness - present at hypochondrium region
Shape of abdomen- scaphoid
Spleen not palpable
Bowel sounds are present
CNS:
Level of consciousness- conscious
Speech - normal
No neck stiffness
CVS-S1 and S2 are heard.
INVESTIGATIONS:
Clinical examination:
PROVISIONAL DIAGNOSIS:
Chronic pancreatitis with pseudocyst
TREATMENT:
1. IVF NS/RL - 75ml/hr
2. Inj Tramdol 100ml IV/TID
3. Inj Pantop 40mg IV/OD
4. Inj.zofer 4mg IV/SOS
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