14 YEAR OLD MALE WITH COMPLAINTS OF PAIN ABDOMEN
G.RAHUL SAI
ROLL NO:52
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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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan.
Patient came to OPD with chief complaints of
Pain abdomen since 10 days
Constipation since 10 days
HOPI:
Patient was apparently asymptomatic 8 years back then he developed pain abdomen and was reffered to private hospital
Pain relieved on taking NSAIDS.
At the age of 9 years patient was admitted with similar complaints to niloufer hospital and was diagnosed with pancreatitis and adviced to take regular medications.
At the age of 13 years patient had similar complaints and was admitted in Care hospital and was diagnosed with Acute on Chronic pancreatitis and was on regular medications (Tab.CREON 25000)
From past 10 days patient had severe pain abdomen , relieved on taking medications and on bending forward position.
Aggravates on eating food .
H/o similar complaints 3 months back
PAST HISTORY:
N/k/c/o DM, HTN,ASTHMA,TB, EPILEPSY
PERSONAL HISTORY:
DIET :Mixed
APPETITE:Normal
SLEEP:Normal
BOWEL MOVEMENTS:Constipation
BLADDER MOVEMENTS:Normal
ADDICTIONS:No
GENERAL PHYSICAL EXAMINATION:
Patient is Concious , Coherent , Cooperative, well oriented to time place and person
Vitals on admission:
TEMP:98.5F
BP:100/70MMHG
PR:82bpm
SPO2:98%@RA
GRBS:94mg/dl
GENERAL EXAMINATION:
No pallor, icterus,cynosis, clubbing, lymphadenopathy, odema
SYSTEMIC EXAMINATION:
CVS: S1; S2 +,No murmurs heard
RS: BAE +
CNS: HMF INTACT ,NFD
Per Abdomen :
INSPECTION:
Shape of abdomen: scaphoid
Umbilicus : everted
No visible swellings, scars, sinuses ,engorged veins,
No visible peristalsis or pulsations
Palpation:
No local rise of temperature
Tenderness + in epigastric region
Liver not palpable
Spleenomegaly present
Percussion: resonant
Auscultation: bowel sounds +
INVESTIGATIONS:
USG ABDOMEN
DIAGNOSIS:
