30.11.2022


This is an online E log book to discuss our patients de-identified health data shared after taking his/his guardian signed informed consent . Here we discuss our individual patient's problems through a series of inputs from the available global online community of experts with an aim to solve those clinical problems with collective current best evidence based input

A patient came to casualty with chief complaint of pain in the abdomen since 2days .
 

History of past illness : 

Patient was apparently asymptomatic 15years back and developed left sided pain diagnosed with renal calculi (for which pcnl surgery was done ) . 4months back patient developed yellowish discoloration in the eyes .  Pain in abdomen for which he was admitted in the hospital and managed consetvatively . Now patient is complaining pain in the  right hypochondrium region non radiating insidious onset  not associated with vomiting . Associated with fever low grade and intermittent relieves on medication.



 History of past illness:
Case of diabetes mellitus type 2 
Not a case of hypertension .


Treatment history : 
Diabeted since 6months 
No asthma , hypertension , TB

Personal history : 
 Patient is married , daily labourer 
Appetite : Normal 
Bowel movement is regular
Diet is nonvegeterian
Patient is an occasional alcoholic drinker 

Family history is not significant 

Physical  examination : 
No pallor 
No icterus
Temperature : 98.4°F
Pulse rate : 80/min
Respiratory rate :16/ min 
BP: 110 /70 mm/hg
SpO2 : 96% at RA litres O2 

Systemic examination 

CVS : normal 

Respiration: normal
Position of trachea : central 
Breath sounds : vesicular 


Abdomen : 
Tenderness at right hypochondrium

CNS : Normal

Reflexes : normal


 
Provisional diagnosis : 

Acute pancreatitis secondary to primary cholelithiasis


Investigations  : 
 


Treatment : 

Inj pan 40mg IV
Inj zofer 4mg IV 
Inj  Tramadol 100mg in 100ml NS 
Inj.HAI
Inj vitamin K 10mg in 100ml NS

Ultrasound scan 










 

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