55 year old male with acute dysentery,? Acute on chronic pancreatitis secondary to Cholelithiasis

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E.Laharika 

Roll no: 29

• I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

CASE PRESENTATION: 

       55 year old male, farmer by occupation presented with chief complaints of: 

•  Loose stools since 5 days
• Pain abdomen 
• Fever

        

HISTORY OF PRESENTING ILLNESS:

 Patient was apparently asymptomatic 5 days back then he had  loose stools (greenish coloured)- 6 to 8 episodes/day in small volume,watery in consistency.

He also complained of pain in the abdomen on consuming food which is colicky type,intermittent,not radiating. 

From past 2 days, he's experiencing frank blood while passing stools ( 1-2 episodes/day) along with watery stools. 

He had Fever for 1 day which is low grade , intermittent in onset and subsided on medication.

H/O weight loss present 

H/O outside food consumption 5 days ago

No h/o  piles

No h/o cough , cold, SOB

No history of nausea / vomiting 

No h/o Burning micturition/Hemoptysis/Melena.

PAST HISTORY:

Patient is not a known case of Diabetes mellitus/hypertension/TB/Asthma/Epilepsy 

No history of any previous surgeries

PERSONAL HISTORY:

Diet-mixed

Appetite-decreased

Sleep-decreased

Bowel and bladder movements- loose motions (now stable)

Occasional alcoholic

Family history:

Not significant 

GENERAL EXAMINATION 

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

He's moderately built and Nourished. 

No pallor 

No icterus

No Cyanosis 

No clubbing 

No lymphadenopathy 

No edema

VITALS:

Temperature-Afebrile

BP- 130/70 mm hg

PR -78 bpm

RR- 17 cpm

Spo2 99% at RA

SYSTEMIC EXAMINATION:

CVS- S1 S2 sounds are heard

RS- Bilateral air entry decreased 

PER ABDOMEN EXAMINATION:

Soft and mild tenderness is present in the hypogastric region. 

Bowel sounds are heard.

No palpable mass or free fluid

CNS - speech is normal

           Reflexes are normal 

           Motor and sensory system-normal

           Cranial nerves-intact

           No meningeal signs

INVESTIGATIONS:

CBP

CUE

Sugar ++++

Blood urea

LFT

SERUM CREATININE 

SERUM ELECTROLYTES 

SERUM AMYLASE 

LIPASE

RANDOM BLOOD SUGAR

GLYCATED  HAEMOGLOBIN

X rays

Ultrasound report 

Impression:

Diffusely altered echotexture of pancreas

Cholelithiasis

Grade 1 fatty liver

Raised echogenicity of both the kidneys

Few tiny renal calculi in left kidney.

ECG:

PROVISIONAL DIAGNOSIS:

Acute dysentery 

? Acute on chronic  pancreatitis secondary to Cholelithiasis 

TREATMENT:

Day 1

1. IVF NS 150 ml /hr

2. Inj. PANTOP 40 mg iv /OD

3. Inj.  Zofer 4mg IV/SOS

4. Inj.Tramadol 1 Amp in 100 ml NL iv/BD

5. Tab PCM 500 mg PO/SOS

6. Inj.METROGYL 400 mg iv /TID

7. Monitoring Vitals 4th holy

8. I /O charting. 

Day 2

Pain abdomen decreased 

1 episode of stool associated with blood 

1.IVF NS,RL,DNS@ 150 ml/ hr

2.INJ.pantop 40 mg iv/od

3.INJ.zofer 4 MG IV/sos

4. Inj.tramadol 1 amp in 100 ml Ns IV/ tid

5. Tab.pcm 500 mg po/ sos

6. Inj.metrogyl 400 mg/iv/tid

7. Monitor vitals 4 th HRLY

8. I/O charting

Day 3

Pain abdomen subsided

No episodes of loose stools

1.liquid diet

2.IVF NS,RL,DNS@ 150 ml/ hr

3.INJ.pantop 40 mg iv/od

4. TAB.Ultracet po/sos

5. Tab.pcm 500 mg po/ sos

6. Monitor vitals 4 th HRLY

7. I/O charting

8.GRBS-6th hrly.