22 yr old male with pain abdomen

 Short case 

1701006104  

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M.Rambai 

1701006104  

CASE 

My case is of a 22 yr old male ,painter by occupation ,came with chief complaints of pain abdomen since 4 days .

HISTORY OF PRESENT ILLNESS 

 Patient started taking alcohol from the age of 18 years , reason for starting alcohol was due to peer pressure ,and later it began as addiction .

He also has habit of smoking cigarettes ,he used to smoke 5 cigarettes per day .

Then ,3 months ago  he developed pain abdomen which was insidious in onset, dragging type and aggravated on standing , eating food and relived on forward bending and lying down .

He went to hospital and was advised to quit alcohol ,so he stopped consuming alcohol .

But he developed alcohol withdrawal features like excessive anger,tremors ,and cravings for alcohol .

4 days back ,he had a fight with his wife and so took alcohol again .

After which ,he had pain abdomen ,but didn't tell to his family members.

In view of his withdrawal symptoms he brought to psychiatry department for de addiction ,and then he said about his pain abdomen ,for which he was referred to medicine department and admitted. 

PAST HISTORY

H/o similar complaint in past 3 months back.

 No h/o previous medical, surgical history. 

FAMILY HISTORY

Not significant 

PERSONAL HISTORY

Diet : mixed 

Appetite : normal

Bowel bladder: regular 

Sleep: inadequate 

Addictions - alcohol consumer,stopped 3 months back . 

GENERAL EXAMINATION 

Pateint is conscious , coherent and cooperative 

Well oriented to time place and person 

Thin built and moderately nourished .

Pallor - absent

No icterus,cyanosis , clubbing,lymphadenopathy, edema 

Patient has Ryles tube connected

VITALS

Temperature- afebrile

Pulse rate- 94bpm

Blood pressure-120/80mmHg

Respiratory rate- 16cpm 

SYSTEMIC EXAMINATION  

ABDOMINAL EXAMINATION 

 INSPECTION 

Shape of the abdomen- flat

Umbilicus is central

No visible scars,pulsations, peristalsis, engorged veins

PALPATION 

All the inspectory findings are confirmed.

Tenderness present over the epigastrium and left hypochondrium region

No local rise of temperature 

Liver - palpable 2cms below costal margin

Liver span: 11.5cm ( normal)

Spleen : not palpable  

PERCUSSION 

No free fluid

AUSCULTATION 

Bowel sounds heard 

RESPIRATORY SYSTEM 

 Bilateral air entry present  

Normal vesicular breath sounds 

 no added breath sound

CVS : 

S1 S2 heard 

 no added murmurs 

CNS : 

Higher mental  functions- intact 

No motory and sensory deficit.

Cranial nerves normal 

INVESTIGATIONS 

Lipase levels 

Blood grouping 

Blood sugar 

RFT 

USG 

PROVISIONAL DIAGNOSIS 

Pseudocyst of pancreas

TREATMENT

*Nil per oral

*IV fluids - Ringer lactate ,Normal saline 100 ml per hour

*Inj. Tramadol100mg in 100ml NS IV BD

*Inj.pantop 40 mg IV OD

*Inj. Optineurin 1 ampoule in 100ml NS IV OD 

Psychiatry medication

Tab . Lorazepam 2mg BD

Tab . Benzothiamine100mg