26 year old male with c/o abdominal pain
Note: This is an online E Log book recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.
-Ajitesh Racharla 07
-Anirudh Mane 12
A 26 year old patient cab driver by occupation came to the hospital with c/o abdominal pain around the umbilicus
CHIEF COMPLAINTS
The patient has c/o pain in the abdominal region near the umbilicus
And c/o vomitings on the day of addmission
HISTORY OF PRESENT ILLNESS
The patient was apparently asymptomatic 4 months ago.
Had sudden onset of pain in the same region as now and was diagnosed with pancreatitis
HISTORY OF PAST ILLNESSES
Patient was treated for pancreatitis with medication
No surgery was done
No h/o DM HTN asthma TB
FAMILY HISTORY
No h/o similar conditions in his family
PERSONAL HISTORY
He is a driver by occupation and had consumed a lot of spicy fast food due to his profession
Appetite has been decreased since 4 months from the onset of pain
Bowel movements normal
No burning micurition
Diet mixed
GENRAL EXAMINATION
No
Pallor/ icterus/ cyanosis/clubbing/lymphadenopathy/edema
INVESTIGATIONS ORDERED
S amylase, lipase, CXR, ECG, hemogram, LFT, RFT
PROVISIONAL DIAGNOSIS
Acute pancreatitis
TREATMENT
1) IVF NS RL @100 ML/HR
2) INJ TRAMADOL 1 AMP IN 100ML NS IV/SOS
3) TAB PAN 40 MG PO/OD/BBF
4) TAB ZODER 4 MG PO/SOS
5) TAB PANCREATO FLAT PO/OD
6) SYP CREMAFFIN PLUS 15 ML PO/HS
Comments
Post a Comment