Acute pancreatitis

 This is 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 patients’ clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient centred online learning portfolio and your valuable inputs on comment box is welcome. 

 I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan

Name - S.Kavya 

Rollno - 121

 A 32 yr old male, who is lorry driver by occupation came to the opd with C/O 

PAIN abdomen since 3days

Vomitings 2 episodes on 28/10/21

HOPI:

  patient was apparently asymptomatic 4years ago then he developed pain in the abdomen for which he went to the local hospital where he was diagnosed with acute pancreatitis and treated for it , he was told to stop consuming alcohol and he was discharged, after that he occasionally takes alcohol.

Again he had similar complaints  in September after having alcohol, for which he got treated here. 

  Now , he presented to our hospital again  with the complaints of  pain in the  abdomen  since 3days which was insidious in onset, gradually progressive and it is localized to epigastric and periumbilical region and it was squeezing type of pain and non radiating type, aggravating on eating and on drinking , no relieving factors. 

There is associated nausea and vomiting

Vomiting - 2 episodes, non projectile, non- bilious, and contents are food particles. 

no h/O fever, cough, constipation

PAST HISTORY ; 

he had similar complaints 4 yrs back for which he got treated. 

Again he had similar complaints  in September after having alcohol, for which he got treated here. 

Not a k/c/O DM, HTN, asthma, epilepsy, CAD. 

No surgical history

PERSONAL HISTORY:

DIET: mixed

Appetite; normal

Bowel and bladder; regular

Sleep ; adequate

No known allergies

Addictions; occasionally he takes alcohol. 

FAMILY HISTORY: not significant. 

GENERAL EXAMINATION;

he is conscious, coherent, cooperative, well oriented to time, place, person . 

He is moderately built and moderately Nourished

Vitals; 

Temp; Afebrile

PR ;90 bpm

RR; 18 cpm

BP;130/90 mm of Hg

NO pallor, icterus, clubbing, lymphadenopathy, edema

SYSTEMIC EXAMINATION;

RS; BAE+

CVS; S1, S2 heard

CNS: Intact

P/A ; Soft and tenderness is present in epigastric region and around Umbilicus

Bowel sounds are heard

PROVISIONAL DIAGNOSIS; 

ACUTE PANCREATITIS secondary to Alcohol

Treatment