31 year old male with pain epigastrium.

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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: 31 year old male resident of miryalaguda , mechanic by occupation came with a chief complaints of Pain Abdomen since 4 days.



History of present illness: 
Patient was apparently asymptomatic 4 days back then he developed pain in the Epigastric region which is sudden in onset and continuous in nature and radiating to back.
No aggravating and relieving factors.
Pain associated with one episode vomiting which watery in content, non bilious and non projectile .
No associated fever with chills and rigor.

Past history:
No similar complaints in the past.
Not a known case of diabetes ,hypertension and epilepsy.

Family history:
Not significant

Personal history:
Diet :Mixed
Appetite:Normal
Bowel and bladder movements : Regular
Sleep :Adequate
Addictions:
Chronic Alcoholic since 10 years consuming 180ml of alcohol on every alternate days.

General examination:
Patient was conscious ,coherent and cooperative.
Moderately built and nourished.
No pallor ,icterus,clubbing,cyanosis,koilonychia and lymphadenopathy.
Vitals :(measured at 11:15Am on 8th March 2021)
Afebrile
BP : 110/80 mm hg
RR:20 cpm
PR:70bpm
Systemic examination:
On inspection:
Shape of abdomen is normal
No scars,pigmentation
Umbilicus is inverted in position
All the quadrants are moving equally on respiration.
No visible peristalsis.
No dilated veins.

On palpation:
Tenderness present over epigastric region
On Auscultation:
Bowel sounds are heard.

Following is my analaysis in this case:

Anatomical location :
Pancreas , intestine

Etiological :
Alcoholic since 10 years

Investigations:

Provisional diagnosis:
Acute pancreatitis

Treatment given :
IV NS with Injection Tramadol
Injection pantop
Injection zofer
Bowel rest

Thanks and regards,
Shravani Reddy.













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