A 55 yr old male patient came with a complaint of abdominal pain

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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. 

CHEIF COMPLAINT : A 55 yrs old male patient came to causality with a complaint of abdominal pain since 10 hrs

HISTORY OF PRESENT ILLNESS  : A 55 yr old male patient  who is cook by occupation  was apparently  asymptomatic  10hrs  back then he noticed continuous throbbing type of pain in the abdomen,cough which relived to some extent on medication first he visited a  near by local hospital 

PAST HISTORY:

Similar complaint 1yr back ( pain in the abdomen) 

PERSONAL HISTORY:

Diet  : mixed  

Appetite  : normal

Sleep : adequate 

Bowel and bladder movements  : regular

Micturation : normal

Addiction : Alcohol (90ml/day)$ amber since 20 yrs

FAMILY HISTORY  :    no relevant  family history 

GENERAL EXAMINATION  : patient is conscious coherent   cooperative and well orientated  to  time place and person 

Moderately  built

No h/o pallor  cyanosis  clubbing edema 

Lympadenopathy 

Vitals :

Temp : 98.4°F

Bp: 110/80mmhg

RR :16

PR : 90

SYSTEMIC EXAMINATION  :

CVS  : no thrills 

No cardiac murmurs

Heart sounds : s1 s2 +

RS : no wheeze no dysponea 

CNS : Consicous 

No neck stiffness 

Speech :  normal 

Abdomen  : scaphoid 

Mild tenderness near the gastric region 

DIAGNOSIS :

Acute pancreatitis 

INVESTIGATIONS:

Ultrasound  

ECG 

TREATMENT  :


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