32 year old male with abdominal pain

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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 to come up with a diagnosis and treatment plan.

A 32 year old male, daily laborer by occupation, came to OPD with chief complaint of abdominal pain since 1 day.

History of presenting illness :

Patient was apparently asymptomatic one day back, later he developed diffuse abdominal pain at night, which was insidious in onset, continuous and non- radiating in nature, aggravated on consuming food, and not relieved on medication.

History of passing hard stools since three days.

History of decreased bowel movements since yesterday evening.

No history of fever, chills, nausea, vomiting, abdominal rigidity, decreased urine output, burning micturition,  regurgitation, edema.

Past history :

Patient had similar complaints in the past.

Not a known case of diabetes, hypertension, epilepsy, asthma, tuberculosis, thyroid, cardiovascular diseases.

Personal history :

Lorry driver by occupation since 2010

Later in 2020, continued as daily laborer.

Patient has a mixed diet, normal appetite, adequate sleep, bladder movements regular, bowel movement irregular since 3 days

Addictions : alcohol and smoking since 10 years.

90 ml per day with 4 times per week frequency.

Family history :

No relevant family history

Treatment history :

History of hemorrhoids surgery one year ago.

History of medication for abdominal pain after alcohol intake without food consumption.

General examination :

Patient is conscious, coherent, cooperative, well oriented to time, place and person, well nourished and built.

Subconjuctival hemorrhage seen.

No signs of pallor, icterus, clubbing, cyanosis, koilonychia, lymphadenopathy, edema.

Vitals : 

Temperature - afebrile 

Pulse rate - 87 BPM

Respiratory rate - 16 cpm

BP - 130/90 mm Hg

SpO2 - 98% at room air

Systemic examination : 

Abdominal examination - 

Inspection :-

Shape of abdomen is distended.

Flanks full.

Umbilicus is everted.

Intact hernial orifices

No sinuses, scars, swellings, engorged veins, visible palpations or peristalsis.

No flapping tremors, spider naevi, palmar erythema.

Palpation :-

No local rise of temperature.

Tenderness in hypogastric region, and right hypochondrial region.

Liver not palpable.

Spleen not palpable.

Fluid thrill negative.

Percussion:- 

Tympanic note heard.

Auscultation:-

Bowel sounds heard.

No bruit.

On Respiratory system examination -

On inspection:- 

Normal shaped chest, trachea appears to be in centre, no scars and sinuses present,abdomino thoracic type of respiration, normal respiratory movements present

On palpation:- 

All inspectory findings are confirmed on palpation. 

On percussion:-          Right            Left

                  

Infraclavicular           normal       normal       

Mammary                 normal          normal

Axillary.                     normal        normal

Infraaxillary            normal        normal

Suprascapular        normal         normal

Infrascapular          normal       normal

Upper, mid, lower     

Interscapular             normal       normal

On auscultation:- 

Normal vesicular breath sounds heard.

Cardiovascular system:-

Inspection -

no apical impulse

chest wall normal in shape

no precordial bulge

no dilated viens,scars,sinuses

no visible pulsations

 

Palpation -

apex beat present in the 5th intercoastal space in midclavicular line

no other pulsations felt

no thrills

Percussion -

Normal

Auscultation -

S1, S2 heard no abnormal sounds

CNS - 

No focal neurological deficits

Oral cavity examination:- 

Presence of dental caries.

No signs of oral thrush, tonsillitis, gum hypertrophy, fetor hepaticus.

Investigations - 

On 4/1/23,

Treatment history :

Inj. Thiamine 100 mg IV/OD in 100ml NS.

Tab. Pantop 40 mg PO/OD

Tab. Udiliv 300 mg PO/BD

Tab. Viboliv 500 mg PO/OD

Tab. Rifagut 550 mg PO/BD

Syrup lactulose 15 ml PO/BD

Vitals monitoring 6th hourly 

NS - 75 ml/hr

On 6/1/23, 

Inj. Thiamine 100 mg IV/OD in 100ml NS.

Tab. Pantop 40 mg PO/OD

Tab. Udiliv 300 mg PO/BD

Tab. Viboliv 500 mg PO/OD

Tab. Rifagut 550 mg PO/BD

Syrup lactulose 15 ml PO/BD

Vitals monitoring 6th hourly 

NS - 75 ml/hr

Syrup sucralfate 15ml PO/BD

Provisional diagnosis :

Alcoholic hepatitis (?)

Abdominal pain under evaluation