A 28 YEAR OLD MALE WITH ACUTE PANCREATITIS.

124 SHAREENA
30/3/22.

Thisis 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.

 28 year old male, resident of Hyderabad and tailor by occupation came to OP

CHIEF COMPLAINTS: pain in abdomen since 3 days in epigastric region.
Vomitings since 1 day.
HOPI:
Patient was apparently asymptomatic 3 days ago,then he developed pain in epigastrium which is colicky type radiating to back.
Aggrevated on taking meals.
And some relief on leaning forward.
Pain is insidious in onset and gradually progressive.
3 days back he went to the RMP because of the pain.after taking medication pain decreased for 1 day,but on the nxt day pain increased.

Vomiting:
2 episodes of vomiting on the 2 day ,non projectile,non bilious,with food particles as  the content.
No history of loose stools ,constipation,fever.

Past history:
No history of trauma.
8 years ago patient had cholelithiasis.which was diagnosed on endoscopy.
Not a known case of DM, hypertension,CAD,asthma,TB.

Treatment history:

He underwent endoscopic surgery for cholelithiasis 8 years back.

Personal history:
Diet:mixed.

Sleep: disturbed sleep since 3 days.

Appetite:normal

Bowel and bladder: regular.

No addictions.

Family history:

No one in his family have similar complaints.

General examination:

Patient was conscious,coherent and cooperative.

Built is moderate.

There is no pallor,icterus,cyanosis, lymphadenopathy, clubbing.
 Vitals:
Temperature: afebrile
Pulse rate:127/min
Respiratory rate:16/min.
BP:110/70.
Spo2:90%
GRBS:109 mg %


Systemic examination:

CVS: S1 and S2 are heard.
No murmurs and thrills.

Respiratory examination:
There is no dysnoea,wheeze.
Breath sounds are vesicular.

Abdominal examination:
Inspection:
Shape of the abdomen:scaphoid
No scars and sinuses.
No engorged veins.
Palpation:
Tenderness is present in epigastric region.
Liver and spleen are not palpable.
Bowel sounds are sluggish.

CNS:
NAD

 
Investigations:
Serum amylase:528IU/ lt.
Serum lipase:124IU/lt.
Blood urea:50mg/dl.



provisional diagnosis:
Acute pancreatitis secondary to gall stones.

Treatment:
Inj.Tramadol
100 ml of ringer lactate-IV.








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