A 67 year old male patient with pain abdomen since 4 days

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan

A 67 year old male Patient came to OPD with chief complaints of pain abdomen since 4 days and at present the pain aggravated 

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

H/o sob grade 2 mmrc 

No h/o palpitations,edema, PND, ORTHOPNEA.

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

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, no murmurs

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 

ray erect abdomen 

Chest x ray : 

INVESTIGATIONS ON 28/11/2023

Final diagnosis : 

Chronic pancreatitis

SOAP NOTES: DAY 1 

S : c/o pain abdomen

No nausea, vomitings 

No fever spikes 

O : O/E  pt is c/c/c 

Temp 

PR. 69 bpm

Bp. 120/70 mm hg 

Spo2 97 % at RA

GRBS 192 mg/dl

RS BAE + ,NVBS,No added sounds 

P/A : Guarding+ , tenderness+ bowel sounds heard 

Cvs s1,s2 heard 

No murmurs

CNS  NFND

A : acute on chronic pancreatitis 

P: NBM untill further orders 

IVF ns @ 100 ML/hr 

Inj ceftriaxone 2 g /IV / BD 

INJ METROGYL 500 mg IV /TID

Inj thiamine 200 mg in 100 ML NS IV/tid 

Inj Tramadol 100 mg in 100 ML NS IV/BD 

INJ PAN 40 Mg IV /OD 

INJ ZOFER 4 Mg IV /BD

Day 2 

S : c/o pain abdomen reduced

No nausea, vomitings 

No fever spikes 

O : O/E  pt is c/c/c 

Temp 

PR. 84 bpm

Bp. 110/70 mm hg 

Spo2 97 % at RA

GRBS 108 mg/dl

RS BAE + ,NVBS,No added sounds 

P/A : Guarding+ , tenderness+ bowel sounds heard 

Cvs s1,s2 heard 

No murmurs

CNS  NFND

A : acute on chronic pancreatitis 

P: NBM untill further orders 

Inj ceftriaxone 2 g /IV / BD 

INJ METROGYL 500 mg IV /TID

Inj thiamine 200 mg in 100 ML NS IV/tid 

Inj Tramadol 100 mg in 100 ML NS IV/BD 

INJ PAN 40 Mg IV /OD 

INJ ZOFER 4 Mg IV /BD