37Yr old male came with c/o Pain abdomen in umbilical region since 1day

This is an online E log book to discuss our patient's   
de-identified health data shared after taking 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 is welcome.

A 37yr old male came with c/o Pain abdomen  in umbilical region severe type which was sudden in onset,non radiating associated with vomitings bilious type, non projectile 25 episodes since morning

Patient apparently asymptomatic 10yrs back then he developed pain in epigastric region radiating to back,where he was taken to near by RMP and given NSAIDs,further pt had similar episodes every yr...for which pt took same treatment from RMP

In Dec 2020 pt was taken to  Asian institute of gastro,where he was diagnosed with pancreatitis ,he didn't get that report

Pt complains of pain after having heavy meal (Nonveg/spice food) 

Patient was diagnosed with RENAL CALCULI 5yrs back which was 2mm in size didn't take any medication

No h/o fever,constipation,cold,cough,loose stools,malena

Pt observed wt loss since 10yrs ,initial wt-80kgs,now pt wt is -60kgs

K/c/o diabetes since 10yrs and pt is on irregular Medication

K/c/o alcoholics since 16yrs takes 90ml weekly thrice,smoker occasionally.

On O/E-

Pt is conscious,coherent,and co-operative

No pallor,icterus,cyanosis,lymphadenopathy

Temp-98.6°f

BP-110/80mm of hg

PR-98bpm

SpO2-98%

CVS-S1S2 heard ,no murmurs

RS-On inspection -upper respiratory tract                                     intact. 

      On palpation-Trachea- in central

      On auscultation-NVBS heard,no crepts

Per abdomen-soft &non tender.

On the day of admission-



 

Provisional diagnosis-

?chronic pancreatits

Diagnosis--alchohol depdendance syndrome

Treatment given-

1.IVF -RL(1)&NS(1) @50ml/hr

2.INJ.HAI S/C TID after informing attenders

3.INJ.THIAMINE 100mg in 100ml NS

4.INJ.PANTOP 40mg IV/BD

5.INJ.OPTINEURON 1ampule in 100ml NS

6.Syp.DULCOLEX SUPPOSITORIES

7.Syp.CREMAFINE PLUS 5ml/day

8.Syp.SUCRALFATE 

10ml po

9.Strict grbs charting

10.BP,PR,RR evry 4th horly monitoring.






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