Gm practical long case

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Chief complaint:

A 27 year old, male patient electrician by occupational came with chief complaints of pain in the abdomen since 3 months .

HISTORY OF PRESENT ILLNESS :- 

patient was apparently a symptomatic 3 months back, then he had a trauma where his relatives beaten him with stick at the left hypochondrium region and then he developed mild diffuse abdominal pain associated with bilious vomiting, projectile, contains food particles , then the pain subsided on taking medications 

After a few days he again developed pain in the abdomen at the left hypochondrium region and the pain radiating to back , then he went to government hospital where he under went treatment but the symptoms didn't subsided 

So he went to a private hospital where he took treatment but in the middle of treatment , he tested postive in the hospital , so he went to home isolation , were he approached a local rmp for the pain abdomen and covid .

After 5 days he tested negative in mid of January so he went back to the same private hospitaland under went treatment and his symptoms resolved and the doctors said that there may be chances of symptoms appear again.he didn't complain of any symptoms for the next days

Then after he developed pain again he now tolerated the pain for 3 days after which he came to our hospital with the cheif complaints of pain abdomen at the left hypochondrium and epigastric region which is intermittent , squeezing type of pain and the pain radiating to the back where there is the pricking type of pain and the pain radiating to the left shoulder .

The pain is aggreavted with walking, sleeping after a prolonged duration of sitting and relieved when he bends forward .

PAST HISTORY :- 

NO H/O dm, htn, asthma, epilepsy

No previous surgical history 

PERSONAL HISTORY 

diet : mixed 

Appetite : decreasd since 10 days 

Sleep : inadequate 

Bowel & bladder : regular 

addictions :- h/0 of alcoholic intake since 5 years , regular intake of alcohol and the there is a high intake of the alcohol . he stopped the intake of alcohol 2 months back 

FAMILY HISTORY : No relevant family history.

ON EXAMINATION : 

Patient is conscious, coherent, cooperative.

 pallor , Icterus,clubbing, cyanosis , koilonychia, edema are absent

VITALS 

Temp- Afebrile 

Bp-100/80 mm hg

Pr- 84bpm

Rr-16cpm

Spo2- 99% on RA

Grbs : 102

SYSTEMIC EXAMINATION : 

RS- bilateral air present 

Cvs- S1 S2 heard.

P/A - tenderness present in epigastric region and left hypochondrium 

no gaurding 

bowel sounds present 

CNS - NAD .

INVESTIGATIONS :- 

HEMOGRAM 

HB - 10.5 GM/DL 

TLC -10,500 

PCV - 32.5 

MCV - 82.7 

MCHC - 32.6 

RBC - 3.93 

PL -  5.5 

LFT :- 

TB - 0.48 MG/DL

DB - 0.17 MG/DL

SGOT - 13 IU/L 

SGPT - 14 IU/L 

ALP - 291 IU/L

Tp -  5.9 gm/dl 

albumin - 2.92 gm/dl 

A/G RATIO -  0.98 

SERUM AMYLASE - 292 

SEROLGY - NEGATIVE 

CRP POSITIVE - 2.4 MG/DL

Provisional diagnosis: pancreatitis with large pseudocyst.

TREATMENT GIVEN 

1) IVF NS /RL @75 ml / hr 

2) inj Tramadol 100 ml IV /TID 

3) inj pantop 40 mg iv/ OD 

4 ) inj zofer 4 mg iv/sos

5) plan to get CECT abdomen today and also gastro opinion