27 yr old male with pain Abdomen
A 27 years male patient electrician by occupation came with
CHIEF COMPLAINTS:- pain abdomen since 3 months .
HISTORY OF PRESENT ILLNESS :-
Patient was apparently a symptomatic 3 months back, then
* He had a trauma where his relatives beaten him with stick at the left hypochondrium region and
*then he developed mild diffuse abdominal pain associated with bilious vomiting .projectile .contains food particles , 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 , then he went to government hospital where he under went treatment but the symptoms didn't subsided
*So he went to a private hospital we he took treatment but in the middle of treatment , he tested postive in the hospital , so he went to home isolation , were he approached a local rmp for the pain abdomen and covid .
*After 5 days he tested negative in mid of January so he went back to the same private hospitaland under went treatment and his symptoms resolved and the doctors said that there may be chances of symptoms appear again.he didn't complain of any symptoms for the next days
*Then after he developed pain again he now tolerated the pain for 3 days after which he came to our hospital with the cheif complaints of pain abdomen at the hypochondrium and epigastric region which is intermittent , squeezing type of pain and the pain radiating to the back where there is the pricking type of pain and the pain radiating to the left shoulder tip
*The pain is aggrevated with walking, sleeping after a prolonged duration of sitting and relieved when he bends forward.
*Patient when complaining of pain done cect abdomen 1/12 /2021 where the impression is pancreatitis with pseudo cyst
PAST HISTORY :-
NO H/O Dm, htn, asthma, epilepsy,CAD.
No previous surgical history .
PERSONAL HISTORY
Diet : mixed
Appetite : decreasd since 10 days
Sleep : inadequate
Bowel & bladder : regular
Addictions :- h/0 of alcoholic intake since 5 years , regular intake of alcohol and the there is a high intake of the alcohol . he stopped the intake of alcohol 4 months back
FAMILY HISTORY : Not significant
ON EXAMINATION :
*Patient is conscious, coherent, cooperative.
* Pallor , Icterus,Clubbing, Cyanosis , Koilonychia, Edema are absent
VITALS
Temp- Afebrile
Bp-100/80 mm hg
Pr- 84bpm
Rr-16cpm
Spo2- 99% on RA
Grbs : 102
SYSTEMIC EXAMINATION :
RS- Bilateral air present
CVS -S1 S2 +; No Murmurs.
PER ABDOMEN -
1)Tenderness present in epigastric region and left hypochondrium
2)Rigidity present in the epigastric region and left hypochondrium
3)No gaurding
4)Bowel sounds present
CNS:- NAD
GCS - 15/15
INVESTIGATIONS :-
#HEMOGRAM -
HB 10.5 GM/DL
TLC #10,500
N/L/E/M/B. #135/20/#40/05/00
PCV #32.5
MCV # 82.7
MCHC 32.6
RBC. #3.93
PLT. 5.5
CUE :-
ALBUMIN. NIL
BILE SALTS AND PIGMENTS NIL
PUS CELLS NIL
LFT :-
TB 0.48 MG/DL
DB 0.17 MG/DL
SGOT 13 IU/L
SGPT. 14 IU/L
ALP. # 291 IU/L
Tp. # 5.9 gm/dl
albumin. #2.92 gm/dl
A/G RATIO. 0.98
SERUM AMYLASE. 292
SEROLGY. NEGATIVE
CRP POSITIVE 2.4 MG/DL
USG:-
ECG:-
CECT:-
CHRONIC PANCREATITIS WITH PSEUDOCYST .
TREATMENT:-
1) IVF NS /RL @75 ml / hr
2) Inj Tramadol 100 ml IV /TID
3) Inj pantop 40 mg iv/ OD
4 ) Inj zofer 4 mg iv/sos.
5)Syrup. Cremaffin plus 15/ml/po.
