A28 YEAR OLD MALE WITH ACUTE PANCREATITIS.

Name: Y .Navya Sahithi Reddy

Roll no: 146

Date : 30-03-2022.

This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome. 

A 28 Year old male resident of hyderabad and tailor by occupation came to the opd with 

Cheif complaints of:

1.pain in the abdomen 3 days back in the epigastric region.

2.vomitings since 2 days.

HOPI :

Patient was asymptomatic 3 days ago later  he developed pain in the abdomen which colicky type of pain ,incidious in onset gradually progressive  and it is radiating backwards and aggrevated after taking meals.

Some relief on leaning forward.

Vomtings:

There were 2 episodes of vomitings since 2 days which is non prohectile,non bilious,food particles as content.

There was no h/o loose stools,constipation,fever.

PAST HISTORY:

There is no history of trauma.

Patient had cholelithiasis 8 years ago diagnosed by endoscopically.

There is no history of DM, HTN,Asthma,TB.

TREATMENT HISTORY:

There is history of endscopic surgery for cholelithiasis.

PERSONAL HISTORY:

DIET: MIXED

SLEEP: DISTURBED SINCE 3 DAYS DUE TO PAIN

APPETITIE: ADEQUATE

BOWEL AND BLADDER MOVEMENTS: REGULAR.

NO ADDICTIONS.

FAMILY HISTORY:

No one in his family have similar complaints .

GENERAL EXAMINATION:

Patient was conscious ,coherent cooperative,moderately built.

There is no pallor,cyanosis,lympadenopathy,clubbing,icterus,edema.

Vitals:

Temp: afebrile

Pulse rate-127/min

Redpiratory rate- 16/min

BP: 110/90mm of hg

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.

USG: Tiny focal caliculi.

ECG:

provisional diagnosis:

Acute pancreatitis secondary to gall stones.

Treatment:

Inj.Tramadol

100 ml of ringer lactate-IV.