67 old male patient with pain abdomen
67 year old pateint with pain abdomen since 4 days
G.Aksharakruthi Roll no 40
Patient came to OPD with chief complaints of pain abdomen since 4 days
HOPI :
Patient was apparently asymptomatic 4 days back then he developed pain in the abdomen, insidious in onset, gradually progressive dragging type,aggravated on doing work ,after consumption of alcohol ,not associated with nausea,vomitings
No h/o fever,cold,cough
No h/o constipation ,diarrhea
H/o burning micturition
Past history
N/k/c/o HTN, Asthma, epilepsy,TB , CAD,CVA
No h/o surgeries in the past
No H/O blood transfusion
No h/o radiation exposure
Personal history: patient is farmer by occupation
Diet mixed
Appetite decreased since 4 days
Sleep adequate
Bowel regular
Micturition not normal
Burning micturition
SLEEP ADEQUATE.
Addictions regularly consumes alcohol about 90 ml/day
Since 30 years
Daily routine:-Patient wakes up at 6:30 to 7:30 am in morning approx. and goes to farm for about 1 and half hour and freshen ups and have a cup of tea and goes for farming then he will have his lunch at 2:00 .will have tea in evening and have dinner early and goes to bed at 9:00 Alcohol comsumption is frequent General physical examination
Pt is conscious coherent cooperative well oriented to time place person
Moderately built and nourished
Vitals
Bp : 130/80 mm Hg
Pr : 69 bpm
Spo2 98 on RA
Temp: 98.3 F
Grbs 197 mg/dl
No pallor, cyanosis, clubbing, lymphadenopathy,edema
Icterus present
Systemic examination :
Cvs s1 ,s2 heard
CNS no focal neurological deficits noted
Rs BAE + , NVBS
P/A
Inspection : abdomen flat
No scars,sinuses,hernial orifices, pulses,masses,
All quadrants are moving equally with respiration
On palpation:
All inspectory findings are confirmed
Abdomen soft
Tenderness in epigastric and both hypochondriac regions
No local rise of temperature
Guarding+
Rigidity absent
Provisional diagnosis : acute on chronic pancreatitis
Investigations done on 27/11/23
CBP :
Serum lipase
LFT
AMYLASE
PT
RBS
USG ABDOMEN AND PELVIS
x ray erect abdomen
Chest x ray :
Investigations done on 28/11/23
Final diagnosis :
Chronic pancreatitis
acute on chronic pancreatitis
G.Aksharakruthi Roll no 40
Patient came to OPD with chief complaints of pain abdomen since 4 days
HOPI :
Patient was apparently asymptomatic 4 days back then he developed pain in the abdomen, insidious in onset, gradually progressive dragging type,aggravated on doing work ,after consumption of alcohol ,not associated with nausea,vomitings
No h/o fever,cold,cough
No h/o constipation ,diarrhea
H/o burning micturition
Past history
N/k/c/o HTN, Asthma, epilepsy,TB , CAD,CVA
No h/o surgeries in the past
No H/O blood transfusion
No h/o radiation exposure
Personal history: patient is farmer by occupation
Diet mixed
Appetite decreased since 4 days
Sleep adequate
Bowel regular
Micturition not normal
Burning micturition
SLEEP ADEQUATE.
Addictions regularly consumes alcohol about 90 ml/day
Since 30 years
General physical examination
Pt is conscious coherent cooperative well oriented to time place person
Moderately built and nourished
Vitals
Bp : 130/80 mm Hg
Pr : 69 bpm
Spo2 98 on RA
Temp: 98.3 F
Grbs 197 mg/dl
No pallor, cyanosis, clubbing, lymphadenopathy,edema
Icterus present
Systemic examination :
Cvs s1 ,s2 heard
CNS no focal neurological deficits noted
Rs BAE + , NVBS
P/A
Inspection : abdomen flat
No scars,sinuses,hernial orifices, pulses,masses,
All quadrants are moving equally with respiration
On palpation:
All inspectory findings are confirmed
Abdomen soft
Tenderness in epigastric and both hypochondriac regions
No local rise of temperature
Guarding+
Rigidity absent
Provisional diagnosis : acute on chronic pancreatitis
Investigations done on 28/11/23
Final diagnosis :
Chronic pancreatitis
acute on chronic pancreatitis
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