This is online E log book to discuss our patient's deidentified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve the patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient centered online learning portfolio and your valuble inputs on the comment box is welcome.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 diagnosis and treatment plan.
DOA:2/5/23
Amc bed 1
31 year old male ,farmer by occupation,resident of Nalgonda came to the opd with chief complaints of
Abdominal pain since yesterday night
One episode of vomiting @1:30am today morning
HOPI:
Patient was apparently asymptomatic 1 day ago ,then he developed pain abdomen ,insidious in onset ,gradually progressive,pricking type ,non radiating ,aggravating on consumption of food or water and reliving on bending forward and medications
H/o alcohol intake yesterday night
No h/o Fever ,burning micturition
No h/o constipation or loose stools
No H/o trauma
Past history:
K/C/O DM since 6 months (on irregular medication
Not a K/C/O HTN,epilepsy ,CAD,thyroid
Personal history :
Diet:mixed
Appetite :normal
Bowel and bladder :normal
Sleep : adequate
Addictions: chronic alcoholic since 10 years ( 90-180ml/day )
Family history:
Not significant
General examination:
Pt is conscious,coherent,cooperative
Well oriented to time,place and person
Vitals :
Temp : afebrile
Bp: 120/70mmofhg
PR: 76bpm
RR:17cpm
Spo2:99%at RA
Grbs:103mg/dl
No Pallor
No icterus ,clubbing ,cyanosis ,lymphadenopathy and edema
Local examination; per abdomen
Inspection;
Shape of abdomen; distended
Position of umbilicus: central and inverted
No scars and sinuses are present
All quadrants are moving equally with respiration
Palpation:
Tenderness present in epigastric ,RIF AND LIF
Guarding and rigidity present
No organomegaly
Auscultation:
Bowel sounds are heard
Systemic examination;
RS: BAE+,NVBS
CVS: S1,S2 HEARD
CNS; NO FND
Provisional diagnosis:
Acute pancreatitis with k/c/o type 2 DM
Investigations:
Serology: Negative
CXR:
USG abdomen :
Hemogram on 3/5/23:
Treatment:
1. NBM till further orders
2.IVF NS/RL @75ml/hr
3.Inj.Tramadol IV/sos
4.Inj.HAI according to GRBS
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