45 year old male with pain abdomen

                  GENERAL MEDICINE 


17-11-22

This is an online E log book to discuss our patient's de-identified health data shared after taking his /her/guradian's consent.
This E log book also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box below.

DATE OF ADMISSION: 16-11-22

A 45 year old male laborer by occupation came to opd with

CHIEF COMPLAINTS OF:
. Severe pain in abdomen .

HOPI: 
. The patient was apparently asymptomatic 1 month back and developed  severe pain abdomen which was sudden in onset for which he went to rmp hospital and pain subsided after taking medication for 2 days 

. Again he developed sudden pain in abdomen 1 week back in the epigastric and right hypochondriac region radiating to backside dragging type of pain, no aggrevating or relieving factors
. Associated with 2 episodes of vomiting 
. No h/o fever, burning micturition, chest pain , breathlessness

PAST ILLNESS:
. Known case of HTN from 3 years ( 40 mg telmisartan)
   but he doesn't take it regularly 
. Not k/c/o diabetes, TB , asthma , epilepsy,  CAD, CVA

PERSONAL HISTORY:
diet- mixed
Appetite- decreased appetite since 1 years
Sleep- normal 
Bowel and bladder movements- regular 
Addictions- regular alcohol consumption since 30years

SURGICAL HISTORY 
. No surgical history 

FAMILY HISTORY 
.No significant Family history 

.no known allergic history .


PHYSICAL EXAMINATION 
General examination: 
. The patient is conscious,  coherent, cooperative 
. Well nourished and Moderately built 
. No pallor, icterus, cyanosis, clubbing, lymphadenopathy, Pedal edema 

VITAL SIGNS: on day of admission 

Pulse rate - 82 bpm

Respiratory rate - 16 cpm

Blood pressure - 130/80 mmHg

Temperature - afebrile 


SYSTEMIC EXAMINATION :

Systemic examination :

CVS : S1 and S2 heart sounds hear

NO murmurs and thrill

RESPIRATORY SYSTEM : Bilateral air entry present             

position of trachea - central 

Vesicular breathsounds heard

CNS : 

▪︎NAD and HMF intact

PER ABDOMEN 

Inspection- Umbilicus is central and inverted 

•No engorged veins, scars seen 


Palpation- all inspectory findings are normal 
. Tenderness felt in epigastric and right hypochondriac region and right lumbar region

Percussion: 
•No free fluid 


CLINICAL IMAGES 







 

PROVISIONAL DIAGNOSIS: Acute pancreatitis 

INVESTIGATIONS 

Hemogram


Complete Urine examination 


Liver function test 


RFT


Lipase 


Amylase 



 HBsAg- ELISA



Anti Hcv Antibodies 


Hiv 1 and 2 ELISA

 
Anti HCV antibiodies- rapid 


Usg abdomen 
Ecg



TREATMENT:
. IVF - NS, LS
. Inj tramadol 100mg in 100ml NS over 1hr 
. Tab 40mg pantop
. Tab telmisartan 40mg
. Inj thiamine 100mg in 100 ml iv/ BD

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