40years old male c/o pain in abdomen since 1day

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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