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A 27 year old male patient who is electrician by occupation came with chief complaints of pain in abdomen since 3 months .
HISTORY OF PRESENT ILLNESS:
patient was apparently a symptomatic 3 months back, then he had a trauma where his relatives beaten him with stick at the left hypochondrium region and then he developed mild diffuse abdominal pain associated with bilious vomiting projectile contains food particles , then the pain subsided on taking medications .
After a few days he again developed pain abdomen at the left hypochondrium region and the pain radiating to back , then he went to government hospital where he under went treatment but the symptoms didn't subsided
So he went to a private hospital where he took treatment but in the middle of treatment , he tested postive in the hospital , so he went to home isolation , were he approached a local rmp for the pain abdomen and covid .
After 5 days he tested negative in mid of January so he went back to the same private hospital and under went treatment and his symptoms resolved and the doctors said that there may be chances of symptoms appear again.he didn't complain of any symptoms for the next days.
Then after he developed pain again he now tolerated the pain for 3 days after which he came to our hospital with the chief complaints of pain abdomen at the hypochondrium and epigastric region which is intermittent , squeezing type of pain and the pain radiating to the back where there is the pricking type of pain and the pain radiating to the left shoulder tip
The pain is aggrevated with walking, sleeping after a prolonged duration of sitting and relieved when he bends forward
Patient when complaining of pain done cect abdomen 1/12 /2021 where the impression is pancreatitis with pseudo cyst .
PAST HISTORY:
NO H/O dm, htn, asthma, epilepsy
No previous surgical history
PERSONAL HISTORY
Diet : mixed
Appetite : decreased since 10 days
Sleep : inadequate
Bowel & bladder : regular
Addictions :- h/0 of alcoholic intake since 5 years , regular intake of alcohol and then there is a high intake of the alcohol . he stopped the intake of alcohol 4 months back .
FAMILY HISTORY:
No similar complaints in the family.
GENERAL EXAMINATION
Patient is conscious, coherent and cooperative.
No pallor, cyanosis, icterus and clubbing.
Vitals:
Temp- Afebrile
Bp-100/80 mm hg
Pulse: 84bpm
Respiratory rate:16cpm
Spo2- 99% on RA
SYSTEMIC EXAMINATION :
RS- bilateral air present
Cvs-S1 S2 +
P/A - tenderness present in epigastric region and left hypochondrium
rigidity present in the epigastric region and left hypochondrium
no gaurding
bowel sounds present .
INVESTIGATIONS :-
HAEMOGRAM
HB 10.5 GM/DL
TLC #10,500
N/L/E/M/B. #135/20/#40/05/00
PCV #32.5
MCV # 82.7
MCHC 32.6
RBC. #3.93
PLT. 5.5
CUE :-
ALBUMIN. NIL
BILE SALTS AND PIGMENTS NIL
PUS CELLS NIL
LFT :-
TB 0.48 MG/DL
DB 0.17 MG/DL
SGOT 13 IU/L
SGPT. 14 IU/L
ALP. # 291 IU/L
Tp. # 5.9 gm/dl
albumin. #2.92 gm/dl
A/G RATIO. 0.98
SERUM AMYLASE. 292
SEROLGY. NEGATIVE
CRP POSITIVE 2.4 MG/DL
TREATMENT GIVEN
1) IV NS /RL @75 ml / hr
2) inj Tramadol 100 ml IV /TID
3) inj pantop 40 mg iv/ OD
4 ) inj zofer 4 mg iv/sos
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