GENERAL MEDICINE PREFINAL CASE

 28 YEARS OLD MALE WITH ACUTE PANCREATITIS SECONDARY CHOLELITHIASIS

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Name: KASTURI VIJAY KUMAR 

Roll no: 56

MEDICINE CASE DISCUSSION:

A 28 years old tailor hailing from Urban Telangana has presented with complaints of pain abdomen since 2 days  

HISTORY OF PRESENTING ILLNESS:

The patient was apparently in his normal state of health 8 years ago.Then he developed pain abdomen which was sudden in onset colicky type, aggravated on taking fatty food and relieved  on medication, for which he went to a local hospital where he was evaluated and he was diagnosed with Gall stones. Then he was referred to a higher centre where MRCP was done as a therapeutic procedure. After which he was apparently normal for some months following which he developed similar episodes of pain frequently (twice in 5 months)  for which consulted a local RMP for which he was given some medications (unknown). 

        About 2 days ago he was having a similar episode of pain abdomen which was continuous, colicky type, shooting to the back in standing position. It was relieved  temporarily after bending forwards for some time. He says that he feels more comfortable when he raises his legs or bends forward He also gives history of 2 episodes of vomiting which was projectile, and has food as content. 

No history of loss of appetite but he avoids taking food as pain aggravates  on consumption of food.

No history of jaundice, bowel disturbances, burning micturition and trauma 

PAST HISTORY:

MRCP and ERCP done for Gall stones 8 years ago.

No history of Diabetes ,hypertension ,asthma, TB, epilepsy , CAD

PERSONAL HISTORY :

Appetite :- Good but avoids eating because of pain 

Diet :- Mixed 

Bowel and bladder :- Regular 

Sleep :- Adequate

Addictions:- nil

FAMILY HISTORY:

No history  of similar complaints

GENERAL PHYSICAL EXAMINATION :

Patient was examined  in a well lit room after obtaining valid informed  consent and Adequate exposure

He is conscious, coherent, cooperative

Well oriented to time place person

Moderately built and nourished 

Pallor :- no pallor

Icterus:- no icterus

Cyanosis:- no cyanosis

Clubbing :- no clubbing

Generalised Lymphadenopathy:-no generalised Lymphadenopathy 

Pedal edema:- no pedal edema

VITALS :

Temperature :- afebrile

Respiratory rate :-14 cycles per minute

Pulse:- 86 beats per minute, regular,normal in volume and character, no vessel wall thickening, no radioradial delay

Blood pressure :- 130/80 mmHg  sitting position in right arm 

SYSTEMIC EXAMINATION  :

PER ABDOMEN: 

Inspection:

The abdomen is scaphoid

Umbilicus is central

Mild distension in Epigastric area and flanks are normal

Skin is normal and shiny 

Abdomen wall movements normal with respiration 

No engorged veins

No divarication of recti 

No visible pulsations

No visible peristalsis

No scars and sinuses

Herinal orifices are free

Cullens sign :-absent 

Gray turner sign:- absent 

Fox sign :- absent 

Bryant sign :- absent

 

Palpation:

No local rise of temperature 

Tenderness on epigastrium 

All Inspectory findings  are confirmed

On deep Palpation, Liver, gall bladder and spleen are not palpable

No guarding , rigidity , palpable masses 

Murphys sign :- absent 

Measurements:-

Abdominal girth at level of umbilicus :- 33 inches  

Percussion :-

Tympanic note heard all over abdomen

Shifting dullness absent 

Fluid thrill absent 

Auscultation:- 

Bowel sounds appreciated

No abnormal sounds heard 

RESPIRATORY SYSTEM:

Inspection

Chest is bilaterally symmetrical

The trachea appears to be in centre

Apical impulse is not appreciated 

Chest moves equally with respiration on both sides

No dilated veins, scars or sinuses are seen

Palpation- 

Trachea is felt 

Chest moves equally on both sides on respiration 

Apical impulse is felt in the fifth intercostal space 1cm lateral to mid clavicular line

Tactile vocal fremitus- appreciated 

Percussion-

The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.

They are all resonant.

Auscultation-

Normal vesicular breath sounds are heard

No adventitious sounds

CARDIOVASCULAR SYSTEM- 

Inspection- 

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse or pulsations cannot be appreciated 

Palpation-

Apical impulse is felt in the fifth intercostal space, 1 cm lateral to  the midclavicular line

No parasternal heave felt

No thrill felt

Percussion- 

Right and left borders of the heart are percussed 

Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard 

CENTRAL NERVOUS SYSTEM-

HIGHER MENTAL FUNCTIONS:

Patient is Conscious, well oriented to time, place and person.

All cranial nerves - Intact

No signs of meningeal irritation

Motor system

                              Right.                  Left

BULK 

Upper limbs.        N.                         N

Lower limbs         N.                         N

TONE

 Upper limbs.       N.                        N

 Lower limbs.      N.                        N

POWER

 Upper limbs.      5/5.                    5/5

 Lower limbs      5/5.                    5/5

Superficial reflexes and deep reflexes are present, normal

Gait- normal

No involuntary movements

Sensory system- All sensations (pain, touch, temperature, position, vibration sense) are well appreciated

INVESTIGATIONS:

Pancreatic enzymes 

S. Amylase 124 IU/L(normal-13-60)

S. Lipase 528IU/L(normal-25-140)

HEMOGRAM-

HB 16.3grm/dl

TC 17,100cells/cumm (normal-4000-10000)

PLT 3.38

MCV 82.5

PCV 46

MCH 29.2

MCHC 35.4

SMEAR - NORMOCYTIC NORMOCHROMIC

BGT- O positive

RBS- 124

RFT-

Urea 50mg/dl (normal-12-42)

Creatinine 0.9mg/dl (normal-0.9-1.3)

S. Sodium 140mEq/L(normal-136-145)

S. Potassium 3.8mEq/L(normal-3.5-5.1)

S. Chloride 98mEq/L(normal-98-107)

LFT-

TB 1.38mg/dl (normal 0-1)

DB 0.45 mg/dl(normal-0.0-0.2)

AST 36 IU/L(normal-0-31)

ALT 21IU/L (normal-0-34)

ALP 117IU/L(normal-42-98)

TP 6.7gm/dl(normal-6.4-8.3)

ALB 3.73gm/dl(normal-3.5-5.2)

SEROLOGY: NEGATIVE

 BLOOD SUGAR LEVELS:

RBS-124mg/dl

USG  Abdomen

CHEST X RAY:

ELECTROCARDIOGRAPHY:

Provisional  diagnosis 

Acute pancreatitis secondary to chronic cholelithiasis

TREATMENT:

Diet :- 

On  30/3/2022 he was kept on Nill per mouth 

On 31/3/2022 he was given soft food

Medical management 

1. Inj . Tramadol

2. IV fluids  :- RL and NS  100 ml / hr