Short Case

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A 27 years male patient occupation by electrician came with chief complaints of pain in abdomen since 3 months 

HISTORY OF PRESENT ILLNESS :- 

patient was apparently  asymptomatic 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 were he took treatment but in the middle of treatment , he tested covid 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  tolerated the pain for 3 days after which he came to our hospital with the cheif complaints of pain in 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 aggravated 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 chronic alcohol intake since 5 years , regular intake of alcohol and the there is a high intake of the alcohol . he stopped the intake of alcohol 4 months back.

FAMILY HISTORY : Not significant

ON EXAMINATION : 

Patient  is conscious, coherent, cooperative.

 pallor , Icterus,clubbing, cyanosis ,  koilonychia, edema are absent

VITALS:

Temp- Afebrile 

Bp-100/80 mm hg

Pr- 84bpm

RR-16cpm

Spo2- 99% on RA

Grbs : 102

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 

CNS   NAD 

GCS - 15/15

INVESTIGATIONS :- 

HEMOGRAM 

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 

Serology. NEGATIVE 

CRP POSITIVE  2.4 MG/DL

TREATMENT GIVEN 

1) IVF 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

5) plan to get CECT abdomen today and also gastro opinion