26/M PAIN ABDOMEN
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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.
26 year old male ,resident of coochbehar,farmer by occupation presented with complaints of Abdominal pain since 4 months
Patient was apparently asymptomatic 4 months back , then he developed abdominal pain in the umbilical and right upper quadrant,insidious in onset and gradually progressive,squeezing type,radiating occasionally to right loin region ,no aggravating factors , releived on taking medication from the past two months
H/o Vomitings,7-8 episodes,yellowish in colour,food particles as content,non foul smelling,non blood tinged
No H/o loose stools
No H/o blood in stools
No H/o steatorrhoea
No H/o fever
No H/o jaundice
Dietary History:
Morning -1 cup tea with biscuit
Roti with curry
Afternoon -2 cups rice with dal
and curry
Evening -Tea occasionally
Night -2 cups rice with dal and
Curry
Total average calorie intake:2400-2500
Personal History:
Studied till 10 th class
Diet- Mixed
Bowel and Bladder habits- regular
Consumes alcohol occasionally
Stopped consuming alcohol from the past 2 months as insisted by his physician
Family History:
He is the youngest in the family with 2 sisters elder than him
No H/o similar complaints in the family
Treatment History:
Was diagnosed to have multiple gall stones with largest measuring 6.5mm on usg abdomen in march 2023
Using Ursodeoxycholic acid tablets from 2 months
O/E:
Pt is conscious,coherent and
Cooperative
Afebrile on touch
PR-76bpm
Bp-120/70 mmhg
RR-18cpm
GRBS-111mg/dl
P/A:
Soft,non tender
No organomegaly
Cvs:
S1,S2 +
No murmurs
RS:
B/L air entry +
NVBS Heard
CNS:
No Focal Deficit
Provisional Diagnosis:
Cholelithiasis
Treatment:
Tab UDILIV 300mg PO/BD (Using from March 2023)
Patient was apparently asymptomatic 4 months back , then he developed abdominal pain in the umbilical and right upper quadrant,insidious in onset and gradually progressive,squeezing type,radiating occasionally to right loin region ,no aggravating factors , releived on taking medication from the past two months
H/o Vomitings,7-8 episodes,yellowish in colour,food particles as content,non foul smelling,non blood tinged
No H/o loose stools
No H/o blood in stools
No H/o steatorrhoea
No H/o fever
No H/o jaundice
COURSE IN THE HOSPITAL:
A 26 year old male presented with complaints of abdominal pain since 4 months associated with occasional vomitings,on further evaluation he was found to have multiple gall stones with largest measuring 6mm and Hyperechoic foci in the distal common bile duct -?sludge?calculus and cholecystitis on usg abdomen on 9/5/23 .General surgery advise was taken i/v/o Cholelithiasis and ?cbd calculus and was advised with mrcp for further evaluation and management. MRCP was done on 13/5/23 which showed Cholelithiasis with Distal CBD Calculus(6-7mm). Patient counselled regarding further intervention (ERCP with stenting and Cholecystectomy)from their centre of choice.
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