Scribd
Upload
15 views

write up

The document details the case of a 58-year-old male farmer who presented with recurrent left upper quadrant abdominal pain, nausea, and vomiting, ultimately diagnosed with acute pancreatitis. Despite previous treatments for peptic ulcer disease, his condition did not improve, and he had a history of long-term alcohol abuse. The management included intravenous antibiotics, pain control, and a recommendation to abstain from alcohol, with plans for follow-up care.

Uploaded by

Kato Caleb
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
15 views

write up

The document details the case of a 58-year-old male farmer who presented with recurrent left upper quadrant abdominal pain, nausea, and vomiting, ultimately diagnosed with acute pancreatitis. Despite previous treatments for peptic ulcer disease, his condition did not improve, and he had a history of long-term alcohol abuse. The management included intravenous antibiotics, pain control, and a recommendation to abstain from alcohol, with plans for follow-up care.

Uploaded by

Kato Caleb
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 5

Name: M S

Age: 58

Sex: Male

Address: Kayunga

Tribe: Muganda

Religion: Catholic

Education: S4

Marital status: Married

Occupation: Farmer

NOK: HK – the wife

Referral status: from HCIV

DOA: 22nd July 2023

DOD: 26th July 2023.

Presenting Complaint
Abdominal pain x 6/7
History of Presenting Complaint
Was relatively well until a week ago when he noticed new episode of abdominal pain, which was
localized in the left upper quadrant. It was of gradual onset, on and off and was piercing in nature.
The pain radiates straight into the back, aggravated by lying flat and foods and relieved by sitting
and bending forward also on consumption of alcohol. He feels it more at night. It was associated
with nausea, vomiting which is non projectile and non-bilious, loss of appetite, weight loss, and
night sweats. No history of trauma. He also says that he hadn’t experienced any change in his urine
color, smell, frequency, or pain when urinating, has no history of fever, yellowing of eyes and
change in stool color, consistency, or frequency.
Systemic Review
Respiratory- No history of cough, shortness of breath, or chest pain.
Cardiovascular- No palpitation, leg edema, syncope, or easy fatigability.
Nervous System- No headache, dizziness, visual or hearing problem, limb weakness or loss of
sensation.
Musculoskeletal- No joint pain, joint stiffness, or dry eyes.

Past Medical History


He had 3 previous hospital admissions before this for the same problem since August last year when
he got the first episode of this problem. All through he was managed as peptic ulcer disease with
Proton Pump Inhibitors and H2 receptor blocker with little improved. HIV serostatus is unknown,
no history chronic illnesses. No food or drug allergy.
Past Surgical History
No history of abdominal surgery, abdominal trauma or blood transfusions.
Family History
He is the 2nd born of a family of 8. 2 of his siblings died for a disease unknown to him. Both parents
died as well. He remembers that his mother used to complain about her stomach but not sure
whether it was the reason of her demise. No familial disease in the family.
Social History
He is a peasant farmer in Monogamous Relationship with 8 children. All alive and well. There is
long standing history of alcohol consumption although no smoking. He has never smoked.
Summary
58 year old male who presented with an episode of recurrent left upper quadrant abdominal pain
which was radiating straight to the back, associated with nausea and vomiting against a background
of long term alcohol abuse. He had had no improvement despite previous treatment.
General Exam
Sick-looking elderly man who is in obvious pain and seated on a bed while bending forward. He
looks moderately wasted. Had mild conjunctival pallor, and had enlarged submental and
submandibular lymph nodes. Had no jaundice, finger clubbing, oral thrush, or edema. Febrile on
touch with an axillary temperature is 37.3c.
Abdominal Exam
Appears slightly scaphoid and symmetrical. It’s moving with respiration. No obvious masses or
therapeutic marks. No color change around the umbilicus or flanks. Tender on palpation and was
significant in the epigastric, right and left hypochondrium. No masses or enlarged organs were
palpated. No renal angle tenderness. The percussion note was normal. No shifting dullness. Bowel
sounds were heard and were normal. PR was not done.
Respiration Exam

The RR was 20bpm (normal). There are therapeutic marks noted at the left chest. Chest was moving
symmetrically with respiration. Trachea was centrally placed. Chest was non tender and chest
expansion was normal. Vesicular sounds were heard in all lung fields.

Cardiovascular Exam

Pulse- 95bpm normal volume, regular and synchrous with other pulses. BP - 110/75 (normal). JVP
was not raised. Apex beat was palpable at the left 5th ICS mid clavicular line. Heart sounds 1 and 2
were heard. No murmur or gallop.

Central nervous system

The patient was fully conscious, alert, oriented in time, place and person with GCS of 15\15. The
neck was soft and kerning sing not elicited. No craniopathy observed. The motor, sensory and
cerebella function were intact.

Diagnosis

Acute Pancreatitis

Differential Diagnosis
Gastritis

Peptic Ulcer Disease

Cholelithiasis

Cholecystitis

Appendicitis

Small Bowel Obstruction

Management

I.V amoxicillin 500mg TDS 5/7

I.V metronidazole 500mg tds 5/7

Tabs paracetamol 1mg TDS 3/7

Tabs Omeprazole 20mg BD 3/7

Aluminium sulphate suspension o.d

Blood smear for mps

Complete blood count

Haemoglobin estimation

Erythrocyte sedimentation rate

Serum amylase

C reactive protein

Liver function tests

Chest X ray

Abdominal ultrasound

Review by physician

Follow-Up

23/07/2023

Patient still complains of severe abdominal plan.

Plan

BS is negative and all other laboratory investigations could not be done because of lack of reagents.

Consultant Physician review


1. Normal saline to be alternated with 5% dextrose, 2.5 litres in 24 hours.
2. No oral fluid or food intake.
3. Analgesia, Morphine 10mg tds. This was not available at KIUTH, and the patient was not able
to buy it from outside. So he was given Tramadol 100mg which was the only analgesic which
was available.

24/07/2023

Patient reports mild improvement but now complains of fever.

On Examination was still febrile on touch with temperature of 37.5c. Pulse- 95bpm. Blood pressure
of 110/60

Per abdomen – tenderness in the epigastric and right hypochondrium.

24/07/2023

Patient reports improvement, abdominal pain has reduced. No fever. Patient still does not have
money for abdominal ultrasound or chest x ray. Patient requests for discharge.

Plan

Patient is advised on hospital stay and importance of the treatment.

Continue treatment.

26/07/2023

Patient reports marked improvement and no fever.

Plan – Discharge and advised to stop alcohol and to come back in 2 weeks for review.

Discussion

The differential diagnosis for upper abdominal pain is quite broad. They are usually associated with
gastric, small bowel, biliary, pancreatic, lower lung, cardiac, and liver problems.

Mwebaze has presented with an upper abdominal pain which was piercing in nature, and radiating
to the back. It was associated with vomiting, relieved by sitting and leaning forward. It was
worsened by food and alcohol. This is classic presentation of acute pancreatitis. The history of
alcohol abuse is also helpful when making such diagnosis because it’s the second most common
etiologic agent after gallstones. However the possibility of gastritis can’t be underestimated as it
presents with upper abdominal pain and alcohol exacerbates it. Although some of the investigations
could not be done to fully confirm the clinical findings and this was a limitation to proper
management. For example the levels of serum amylase, serum lipase and urine amylase would be
highly diagnostic. Moreover an abdominal ultra sound would be enable rule out liver, biliary,
gastric or small bowel pathology.

Peptic Ulcer Disease (PUD) is usually confused with acute pancreatitis. The pain of PUD is
constant and is referred to the right shoulder. Mwebaze’s pain was obviously different. Furthermore
he didn’t improve when he was mistreated for PUD. Pancreatitis is typically managed medically
with IV fluids, pain control, and NPO status. Surgical consultation would be used in this setting to
treat patients with complicated pancreatitis, such as an impacted gallstone that could not be
extracted with endoscopic retrograde cholangiopancreatography (ERCP). Antibiotic use in
pancreatitis has been studied in controlled clinical trials but remains controversial.

References

1. Lawrence M Tierney, Current Medicinal Diagnosis and Treatment, 45th edition, 2006.
2. www.emedicine.medscape.com

You might also like