GENERAL MEDICINE CASE

 NAME: A Sanvith

ROLL NO: 09

Unit 2 admission:

INTRODUCTION:

A 65 year old male came to  casualty with complaints of  vomitings and pain abdomen since one day.

CHEIF COMPLAINTS:

Patient was apparently asymptomatic one day ago and he had  before  day food,  followed by vomitings of 10 episodes bilious non projectile, food as content. He developed Pain abdomen around umbilicus squeezing type radiating to lower abdomen no aggravating or no relieving factors.


HISTORY OF PAST ILLNESS: COVID 19 PNEUMONIA,  No covid vaccine taken.


Patient attender started observing pedal edema and abdominal distension since one month , not associated with chest pain palpitations ,shortness of breath and increased urine output.

 PERSONAL HISTORY: known case of alcohol since 20 years

O/E:

 VITALS: 

TEMPERATURE AFEBRILE 

pulse rate: 96 BPM

 respiratory rate: 14 CPM 

BP :200/90 mm Hg, 

spo2 98% at Room air. 

Grbs 190mg %

CVS S1 S2 HEARD

RS BAE +

PA: DISTENDED ABDOMEN , TENDERNESS AROUND UMBILICUS EPIGASTRIC AND RIGHT HYPOCHONDRIAC REGION , BOWEL SOUNDS PRESENT

LAB INVESTIGATIONS:

HEMOGRAM: Hb 15.4 TLC 15,500 PC 2.18

SERUM LIPASE- 107


SERUM AMYLASE- 397


LFT:

TB: 1.42
DB: 0.35
AST: 36
ALT: 24
ALP: 176
TP: 6.8
ACB: 4.0
A/G: 1.48

RBS: 193
UR: 4.6
CR: 1.3
Na: 143
P: 4.5
Cl: 102

CHEST X-RAY



PROVISIONAL DIAGNOSIS: 

?Acute pancreatitis



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