49 YEAR OLD MALE WITH PAIN ABDOMEN

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 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable 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


The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

49 year old male came with complaints of abdominal pain since 1 day

HISTORY OF PRESENTING ILLNESS:Patient was apparently asymptomatic 1day back then he developed abdominal pain which was insidious in onset, gradually progressive,radiating to back with no aggrevating and relieving factors.

H/O Vomitings 3 episodes since yesterday night non bilious,non projectile with food and water as contents.

No H/O Fever,Cold and Allergies

PAST HISTORY:

H/O similar complaints 1 year ago

Known Case of DIABETES MELLITUS TYPE 2 Since 1 year on regular medication (GLIMI-M1)

Not a K/C/O HTN,ASTHMA,TB, EPILEPSY,THYROID,CVA,CAD.

FAMILY HISTORY:NOT SIGNIFICANT

PERSONAL HISTORY:

DIET: MIXED

APPETITE:NORMAL

SLEEP: ADEQUATE

BOWEL AND BLADDER: REGULAR

ADDICTIONS: REGULAR ALCOHOL INTAKE SINCE 20 YEARS 90ml per day and STOPPED drinking for 1 year.Later started drinking 1 week ago.

Regular CIGARETTE SMOKER since 20 years 1Pack/day

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS, COHERENT AND COOPERATIVE,Well Oriented to time,place and person.

No pallor,Icterus,cyanosis,clubbing, lymphadenopathy and edema









VITALS:

TEMPERATURE: 98.6°F

BP: 130/70 mm hg

PR: 84 bpm

RR: 17 cpm

SPO2 : 98% at RA

GRBS: 311 mg/dl

SYSTEMIC EXAMINATION:

CVS: S1,S2 HEARD, NO MURMURS

RS: BAE+,NORMAL VESICULAR BREATH SOUNDS HEARD 

PER ABDOMEN:SOFT,NON TENDER,NO ORGANOMEGALY.

CNS:NO FOCAL NEUROLOGICAL DEFICITS

PROVISIONAL DIAGNOSIS:ACUTE PANCREATITIS with k/c/o DM TYPE 2 since 1 year.

INVESTIGATIONS:













TREATMENT:

1.NBM TILL FURTHER ORDERS

2.IV FLUIDS RL,NS @75ml/hr

3.INJ.TRAMADOL 1AMPULE in 100ml NS/IV/SOS

4.INJ.ZOFER 4MG IV TID

5.INJ.PIPTAZ 4.5GM IV STAT

6.INJ.PAN 40MG IV OD

7.INJ.THIAMINE 200MG IV 8TH HRLY


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