CLINICAL
OF ACUTE
Patient Stephen R. 42 years old. Married. Male. Admitted to the hospital
on 15th November 2013 night at around 10.30p.m with dull pain in the
upper abdominal region.
Anamnesis Morbi – The abdominal pain started in the previous evening
at around 6.30p.m after a meal. The nature of the pain is constant and
radiate through the back. The intensity of pain increased and there was also
associated vomiting. He was admitted to the hospital by his son.
Anamnesis Vitae – patient does not have a surgical history. He is a
strong alcoholic but not a smoker. He doesn’t have a past history of similar
symptoms, malaena or hematemesis. Allergic anamneses for drugs are
negative. He denies any viral or bacterial infections. He has a family history
of cardiovascular diseases.
Person Assessment - examination of abdomen at the time of
hospitalization did not divulge any significant findings apart from the
tenderness in the epigastric region. The patient was hemodynamically
stable.
Diagnostic procedure - Serum amylase- is elevated above 1000IU/ml,
Imaging: XR abdomen (supine)- show ground glass appearance, USS of the
abdomen- to find evidence of gall stones. Complete blood count (CBC)
demonstrates leukocytosis, increased serum blood lipase level, increase
urine amylase level.