A 35 yr old with chronic pancreatitis

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians signed informed consent.

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve the patients  clinical problem with current best evidence based input.

This Elog also reflects my patient centered online learning portfolio.

I have 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.

Case scenario 

A 35 year old man, works at a wedding card printing store, presented to the casualty at 8pm with the  complaints of Fever since 2 months

Generalized weakness since 2 months 

Dyspnea on exertion since 2 months 

Pain abdomen since 20 days

Right sided chest pain since 20 days

Vomiting since 20 days 

Dark coloured stools since 20 days

Personal history

He works at a store that prints wedding cards at Suryapet. He has 2 daughters. Since the past 15 years he has been consuming alcohol everyday, he consumes around 360ml of whiskey per day and his last alcohol intake was yesterday.

Since 15 years he has been smoking, he says he only smokes occasionally. 

Since the past 2 years he started to experience  loss of appetite. He also tells us that he started consuming less food and started to consume larger amounts of alcohol. He also tells us that he started to experience recurrent episodes of pain abdomen along with recurrent episodes of vomiting every alternate day and he has visited hospitals 5-6 times over the past 2 years. 

Since the past 2 months he has been experiencing dyspnea on exertion, he says he started to feel dyspneic on walking short distances of less than 100m and also started to experience generalized  weakness so much so that he stopped going for work.

He also tells us that over the past 2 months he has been experiencing low grade fever along with loss of around 12kgs.

20 days back he complains of  one episode of blood tinged vomitus and has been experiencing increased pain abdomen in his epigastric and right hypochondriac region along with right sided chest pain.

He also complains of black tarry stools since 20 days.

History of present illness 

On examination- 

He is a thin built man 

PR - 84bpm, regular

BP - 120/80mmhg

RR - 18cpm

Temp - 98.4 F

Spo2 - 98% on Room Air

Grbs - 102 mg/dl

Pallor +

2 Hypopigmented patches over his abdomen- he has been having them since childhood, pain sensation +

Per Abdomen- 

Diffuse tenderness  +

Guarding +

Bowel sounds +

Cvs - 

Palpable P2 +

Apex beat in 6th ICS at MCL

S1,S2 +

ESM +

Lungs - 

BAE +

Clear

Hb- 3.8 

TLC - 13,500

Plt - 4.8

Peripheral smear - Anisopoikilocytosis with hypochromasia, microcytes with tear drop cells, pencil cells with target cells and few normocytes