A 26 year old male with pain in the abdomen









 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 those 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 valuable inputs on the comment box is welcome.


CASE:

A 26 years old male who came with chief complaints of pain in the abdomen and vomitings on 23/06/2022

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 4 months back.He then developed pain in the abdomen (epigastric region) associated with vomiting for which he was taken to the hospital and diagnosed with acute pancreatitis.

He completed his course of medication.He was advised to stop drinking alcohol,since then he started drinking toddy.

Then on 23/06/2022,he went to a family function where he ate biryani and consumed toddy,when he developed the similar symptoms of pain in the abdomen and vomitings(5 episodes,bilious and non blood stained).

DAILY ROUTINE:

Patient is a car driver by occupation.
He has his breakfast in the morning(8-10:30 am) and
leaves for work.
He eats lunch outside and occasionally dinner too.
He has been a car driver since 8 years and before that he was a finance collector for 2 years.
He has been drinking alcohol since he was 16 years old and drinks beer (1 bottle,twice a week) until 4 months back.
Since he was advised to not drink alcohol, he had started drinking toddy(1 litre, once a month).
 

PAST HISTORY:

Not a known case of diabetes mellitus,hypertension,asthma,epilepsy.


PERSONAL HISTORY:

Diet: mixed
Apetite: decreased apetite 3-4 days back,right now it is normal.
Sleep:adequate 


GENERAL PHYSICAL EXAMINATION:

Pallor:absent
Icterus:absent
Cyanosis:absent
Clubbing:absent
Lymphadenopathy:absent
Pedal edema:absent

VITALS:

Temperature:afebrile
Pulse rate:79 beats per minute 
Respiratory rate:18cpm
BP:110/70 mmHg



SYSTEMIC EXAMINATION:

CVS:S1 and S2 are heard and no murmurs are heard.
RS: Bilateral vesicular breath sounds are normal.
CNS: no focal neurological defect
ABDOMEN: soft and tender.Pain in the epigastric and right hypochondriac region.
Bowel sounds heard.









INVESTIGATIONS:








PROVISIONAL DIAGNOSIS:

Acute Pancreatitis


TREATMENT:

Inj.Tramadol  1amp in 100 ml i.v.BD
Inj.Zofer 4mg i.v.TID
Inj. PAN 40 mg i.v. OD










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