40years old male with pain abdomen since 1 day

 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


• cheif complaint:-  


C/o pain in abdomen since 1day


 • History of present illness:-


Patient is apparently asymptomatic 15yrs back then he developed left side pain(Renal calculi) for which PCNL surgery was done 4 months back pt developed yellowish discoloration of eyes and pain abdomen for which he admitted in hospital and managed conservatively 


Now since 1day patient c/o pain in abdomen in right hypochondrium region,non radiating insidious onset not associated with vomitings,fever,since 2days low grade intermittent type relieved by medication


 • History of past illness:-


H/o DM since 6months


No h/o asthma, epilepsy,CAD, Hypertension, cervical lymphadenopathy


 • Personal history:-


Martial status:- married


Occupation:- Daily wage labour


Appetite -Normal


Diet:mixed


Bowels-Regular


Micturition -Normal


No known allergies


 • Habits/Addictions


              Alcohol-occasional


              Tobacco -No


               betel nut- No


               betel leaf-No


               drug use-No




 • Family History:


No history of DM, CAD, Asthma and thyroid disorders in the family


 • General Examination:


Vitals:


Temp: Afibrile


Respiratory rate:16bpm


Pulse:80bpm


Blood pressure:110/79mmhg


Sp O2 :96%


 • Systemic Examination:


Cardiovascular Examination:


Thrills:no


Cardiac sounds:S1,S2 heard


Cardiac murmurs:no


 • Respiratory system:


Dysponea:no


Wheeze:no


-Abdomen:


Shape of abdomen: Scaphoid


Tenderness:no


Palpable mass:no


Henias orifices:normal


Free fluid:no


Bruits:no


 


-Liver:not palpable


-Spleen:not palpable


-Bowel sounds:yes




-Central Nervous system:


 Pt is conscious


Speech: normal


Signs of meningitis:no


Cranial nerves: normal


Motor and sensory system:normal




-Provisional Diagnosis:


    Acute pancreatitis secondary to cholelithiasis


-Investigation:




















Treatment:

Medication 


 Inj pan 40mg IV od 


Inj zofer 4mg IV sos


Inj tramadol in 100ml NS100mg IV bd


Inj vit k in 100ml NS 10mg od 


Inj thiamine 100ml Ns 10mg IV bdI


Inj hai SC tid

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