27 year old male with pain abdomen

 THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT 

27 year old male painter by occupation was brought to causality with chief complaints of pain abdomen .

HOPI 

Patient was apparently alright 40 days back then he developed pain and burning sensation in the abdomen which is squeezing type and diffuse all over the abdomen relieved after passing stools .

Stool - frequency: 3 times a day , Small amounts , non blood , normal in consistency, mucoid ,non foul smelling , non floating and yellow in color 

Not associated with fever , vomitings ,headache, burning micturation, SOB , cold&cough, chills and rigors.

PAST HISTORY: 

Not a know case of 

hypertension  ,

 Diabetes,

Asthma ,

Tuberculosis,

Coronary heart disease 

PERSONAL HISTORY: 

Appetite : normal 

Diet : mixed 

Bowel and bladder : regular 

Sleep : disturbed 

Addictions :

 alcohol - since 5 years 

                     Daily since 3 years 

                     180 ml

Tobacco- since 5 years 

                4-5 per day 

FAMILY HISTORY: 

 No significant family history 

GENERAL EXAMINATION:

Patient was conscious , coherent, cooperative and well oriented to time , place and person .

Thin built and Ill nourished 

History of 10 kgs weight loss 

Pallor - absent 

Icterus - absent 

Cyanosis - absent 

Clubbing - absent 

Lymphadenopathy- absent 

Edema - absent 

                        

                         

SYSTEMIC EXAMINATION:

CVS -S1 S2 Heard 

CNS - no focal neurologic deficit 

RESPIRATORY - bilateral air entry present 

PER ABDOMEN - tenderness in the left hypogastric region 

VITALS :

TEMP: afebrile 

BP - 110/70 mmhg

PR: 82bpm 

RP: 20cpm 

GRBS : 97 mg/dl 

 INVESTIGATIONS :

UGIE  REPORT : 

 ESOPHAGUS: NO VARICES 

 STOMACH :ERYTHEMA OF THE ARTERIES , PROMINENT GASTRIC FOLDS IN BODY 

IMPRESSION : MILD ANTRAL GASTRITIS

MICROBIOLOGICAL INVESTIGATIONS : 

HIV1/2 rapid test  _ non reactive 

HBsAg rapid - negative 

 

BLOOD SUGAR RANDOM : 97mg/dl 

On :8/6/22

ON 15/7/22

PROVISIONAL DIAGNOSIS : pseudocyst of pancreas

TREATMENT :

• tab Taxim 200mg 
• tab PAN 40 mg 
• INJ tramadol 
• tab vit c 
• tab buscopan 
• tab ultracet