1801006193 SHORT CASE

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CHIEF COMPLAINTS:

A 40 year old male resident of Krishnapuram,

Nalgonda district, field assistant by occupation presented with the chief  complaints of:

. Pain abdomen since 6  days 

. Nausea and vomiting since 6 days

. Abdominal distension since 5 days

HISTORY OF PRESENTING :

Patient was apparently asymptomatic 6 days ago, then he developed pain in abdomen of epigastric region which is severe squeezing type, constant, radiating to the back and aggravated on doing activity and relieved on sitting and bending forward

He developed nausea andvomiting which  was

10-15 episodes which was non bilious ,nonprojectile and food as content.

Then the developed abdominal distension 5 days ago

Which is sudden onset, gradually progressive to current state.

No history of decreased urine output,facial puffiness

Edema; no history of fever, shortness of breath cough

PAST HISTORY:

History of diabetes since 5 years

History of hypertension since 5 years 

No history of asthma; tb; epilepsy and thyroid

PERSONAL HISTORY:

Appétite :decreased

Diet: mixed

Sleep:adequate

Bowel and bladder:regular

Addictions: history of alcohol intake for 5 years

DAILY ROUTINE:

He works as a field assistant under NREGS,Nalgonda from last 15 years, he supervises around 200-250 workers daily. He goes to his work on his bikeat 9 in the morning and comes back home around 5 in the evening.

His colleagues from the work and consumesaround come of whiskey Ona daily basis

  .

 

FAMILY HISTORY:

History of diabetes to patients mother since 14 years 

History of diabetes to patients father since 15 years

  TREATMENT HISPRY:

 metfomin plus glimiperide

 telmisartan 40 mg

GENERAL EXAMINATION:

patient is conscious coherent cooperative and well  oriented to time place and person

adequately build and adequately nourished

pallor absent 

icterus absent 

clubbing absent

cyanosis absent

lymphadenopathy absent

pedal edema absent

vitals:

Temperature 99 f

pulse rate 80 beats pe min

regular rhythm,normal in volume

blood pressure -130/90mm hg measured in the left upper limb in sitting position

respiratory rate 13 breaths per min and regular

SYSTEMIC EXAMINATION:

patient examined in well lit room after taking consent

GASTRO INTESTINAL SYSTEM:

oral cavity: normal

per abdomen:-

inspection:

shape uniformly distended

umbilicus:displaces downwards

skin:no scars,sinuses,scratch marks,striae,no dilated veins hernial orifices

skin over the abdomen is smooth

external genitalia normal 

no local rise in temperature tenderness in epigastric area 

liver not palpable

spleen not palpable

kidneys are not palpable

Abdominalgirth-84cm

Xiphi sternum - umbilicus distance - 21cm 

Umbilicus-pubic symphysis distance-15cb

 spino-umbilical distance -19 cm

Equal on both sides

Percussion:

Shifting dullness-present 

Liver dullness at 5thintercoastal space along 

Midclavicular line-normal

Spleen percussion - normal

Tidal percussion-absent

Auscultation:

Bowel sounds- absent

No bruit or venous hum

Cardiovascular system examination:

Inspection:

Chest wall is symmetrical

Precordial bulge is not Seen

No dilated veins, scars, sinuses

Apical impulse - not seen

Jugular venous pulse-not raised

Palpationi.

Apical impulse-felt at 5th intercoastal space in the

 mid clavicular line

No thrills, no dilated veins

Auscultation: mitral area_ first and second heart sounds heard, no other sounds are heard

Tricuspid area- first and second heart soundsheard, No other sounds are heard

Pulmonaryarea-first and second heart sounds heard, No other sounds are heard.

Aortic area- first and second heart sounds heard; no other sounds heard.

RESPIRATORY SYSTEM:

Inspection:

Chest is symmetrical

Trachea is midline

No retractions

No kyphoscoliosis

No winging of scopula

No scars, sinuses; dilated veins

All areas move equally and symmetrically with respiration

Palpation: resonant

Auscultation: Nvbs

No added sounds

Vocal resonance in all 9 areas - normal

CENTRAL NERVOUS SYSTEM:

All higher mental functions are intact

No gait abnormalities

No bladder abnormalities

Neck rigidity absent

PROVISION DIAGNOSIS:

Ascites secondary to pancreatitis

INVESTIGATIONS:

hg 14.2 (13-17)

Total count 14700

Neutrophils 90

Lymphocytes 5

Eosinophils 2

Monocytes 3

Basophils 0

Platcet count 2.55

LFT:

Total bilirubin:2.1

Direct bilirubin:0.6

SGOT 28

SGPT 17

alkaline phosphates 113

total protein 7.4

albumin 4.1

Serum lipase 186

serum amylase 540

serum albumin 4.1g/dl

ascitic fluid albumin3.3G/dl

SAAG 0.8

Usg abdomen:

Mild to moderate ascot is seen

Final diagnosis:

ascites secondary to acute pancreatitis

MANAGEMENT:

NPO

IV FLUIDS -N/s

inJ pantoP 40mg IV BD

INJ ZOFER 4mg IV SOS

INJ PIPTAZ 2.25mg

tab a long 20 msg od

tab lasix 40 mg bd

GRBS every 4th hourly

inJ tramadol 

inJ HUMAN ACT RAPID ACCORDING TO SUGARS 

therapeutic paracentesis around 1L