CASE HISTORY

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 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-centred online learning portfolio and your valuable inputs on the 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 a diagnosis and treatment plan.

A 37 yr old male, photographer by profession came with the complaints of pain abdomen from 2 days.

HISTORY OF PRESENT ILLNESS 

The Patient was apparently asymptomatic two days back and then he developed pain abdomen which was diffuse all over  abdomen,sudden in onset, non progressive,non radiating,dull aching type associated with 1 episode of loose stools.

No history of vomitings,fever, shortness of breath.

PAST HISTORY

N/k/C/o DM, Hypertension, Thyroid disorders,TB,Bronchial Asthma, Epilepsy.

PERSONAL HISTORY

Diet: Mixed

Appetite: Normal

Sleep: Adequate

Bowel and Bladder movements: Regular

Occasionally alcoholic.

Last intake 90ml whisky.The patient consumed approximately 250ml 3-4 times before the last intake, 2-3days between every binge.

No smoking or tobacco chewing.

FAMILY HISTORY

Not significant

DRUG HISTORY

Not allergic to any known drug.

GENERAL PHYSICAL EXAMINATION

Patient is conscious, coherent, cooperative.Well built and nourished.

Pallor,icterus,cyanosis,clubbing,lymphadenopathy,edema are absent 

VITALS

Temperature: 98.4F

Pulse rate: 67bpm

Respiratory rate: 21cpm

Blood pressure: 140/100mm hg

Spo2: 99@RA

GRBS 129

SYSTEMIC EXAMINATION

CVS :- S1 , S2 heard 

RS :-Bilateral air entry present 

P/A : rigid , tender (diffuse), guarding present, bowel sounds heard, minimal fluid present

CNS :- sensory system intact 

                 motor system.  intact 

                 reflexes normal 

PROVISONAL DIAGNOSIS :- ACUTE PANCREATITIS 

TREATMENT :- 

1.IVF NS, RL, DNS AT 150 ml/hr

2. NBM TILL FURTHER INSTRUCTIONS

3. Inj pantop 40 mg iv /bd 

4. Inj zofer 4 mg iv /sos

5. Inj TRAMADOL 1amp in 100 ml NS iv/tid

6. Inj BUSCOPAN 2cc iv/sos

7. I/O charting

8. Temp charting

9. GRBS charting