72 YEAR OLD WITH PAIN ABDOMEN SECONDARY TO ? CHRONIC PANCREATITIS CLD WITH PORTAL HTN SECONDARY TO CHRONIC ALCOHOLISM PANCYTOPENIA SECONDARY TO HYPERSPLEENISM
DR.ASHFAQ(INTERN)
DR.CHETANA(INTERN)
DR.ABDUL RAHEEM (INTERN)
DR.NAVYA(INTERN)
DR.SRAVYA(INTERN)
DR.GNANADA(INTERN)
DR.CHARAN(PG1)
DR.VAMSI(PG1)
DR.SUSMITHA(PG2)
DR.ADITHYA (PG3)
DR.PRANEETH(PG3)
DR.PRAVEEN NAIK (ASS.PROF)
DR.RAKESH BISWAS(HOD)
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Here is a case i have seen:
72 year old Male patient who was apparently asymptomatic 10 days back came to the hospital c/o pain in the lower abdomen which was insidious in onset, gradually progressive, squeezing type, non radiating, relieves on medication, associated with loss of appetite, not associated with food intake.
Fever since 10 days which was intermittent , low grade, associated with chills, relieves on medication.
No H/o vomitings, loose stools, constipation
No H/o cold, cough, chest pain, shortness of breath
No H/o headache, loss of conciousness, involuntary movements
No H/o burning micturition
No other complaints.
He has underwent cholecystectomy 10 years back
Not a k/c/o DM,HTN, Asthma, epilepsy,CAD,TB.
He is a non vegetarian and has loss of appetite , normal bowel and bladder movements, consumes toddy since 50 yrs.
On examination
VITALS:
Temperature: 99f
Bp: 110/80 mm Hg
Pr: 96 bpm
SpO2: 98%
RR: 18/min
No signs pallor ,icterus, cyanosis, clubbing, koilonychia
No generalized lymphadenopathy and pedal edema.
CVS:
S1,S2 Present
No murmurs
RS:
B/L Air entry present
Normal vesicular breath sounds heard
No added sounds
Per abdomen:
Inspection:
Shape of abdomen-scaphoid
Umbilicus central,inverted
No engorged veins, scars, sinuses.
No visible pulsations.
Palpation:
No local rise of temperature.
Tenderness seen in the umbilical and right lumbar region.
Spleenomegaly +
No guarding.
No rigidity.
Auscultation:
Bowel sounds heard.
CNS:
Higher Mental functions :Intact
No signs of meningeal irritation
(Kernigs sign_negative,Brudzinski Sign_negative)
Cranial nerves: intact
Motor system: intact
Sensory system:intact
REFLEXES RIGHT. LEFT
Biceps 2+. 2+
Triceps. 2+. 2+
Knee jerk. 2+. 2+
Ankle jerk. 2+. 2+
Plantar reflex. Flexor. Flexqor
Investigations:
CBP:
CUE:
CHEST X-RAY:
ECG:
RETICULOCYTE COUNT:
PERIPHERAL SMEAR:
BLOOD UREA:
CECT ABDOMEN AND PELVIS:
CECT ABDOMEN AND PELVIS:
DIAGNOSIS:
PAIN ABDOMEN SECONDARY TO ? CHRONIC PANCREATITIS
CLD WITH PORTAL HTN SECONDARY TO CHRONIC ALCOHOLISM
PANCYTOPENIA SECONDARY TO HYPERSPLEENISM
TREATMENT:
INJ.TAXIM 1gm IV BD
TAB. DOLO 650 mg TID
INJ. PAN 40 mg IV OD
INJ. ZOFER 4 mg IV SOS
IVF. NS
RL
WITH INJ.THIAMINE 1amp
AND INJ. OPTINEURON 1amp
STRICT BP, TEMPERATURE,SPO2, PR, CHARTING 4TH HOURLY.
DR.PRAVEEN NAIK( ASS.PROF)
FACULTY AUTHOR NAME: DR.RAKESH BISWAS(HOD)
