A 55 year old male patient with Abdomen pain

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

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 diagnosis and treatment plan.


 A 55 year old male patient who is Barber by occupation came to the OPD with chief complaints of abdominal pain since 2 days

HOPI:

Patient was apparently asymptomatic 20 years back then he developed abdominal pain which was diagnosed as intestinal perforation for that he undergone surgery. He developed abdominal pain from 2 days which is sudden onset, progressive,dragging type of pain, On day 1 the pain is radiating to chest on lying position.On day 2 pain is limited to abdomen. There is no history of fever, vomiting,nausea,Shortness of breath.

Past History:

Not a known case of diabetes,Hypertension, tuberculosis,epilepsy, Asthma.

Personal History:

Diet:mixed
Sleep: disturbed due to pain
Appetite:normal
Bowel bladder movements: regular 
Addictions: alcohol consumption since 25 years 90 per day 

Family History:
No significant

General Examination:

Patient is conscious,coherent and cooperative well oriented to time,place,person
No signs of pallor,icterus,clubbing,cyanosis,lymphadenopathy,Edema.

Vitals:
Temp:afebrile
Pr:98bpm
Rr:18cpm
Bp:140/100
Spo2:98%

 Systemic examination:

Cvs: S1,S2 heard,no murmurs heard

Rs:BAE +,NVBS heard

Abdomen Examination:

Inspection: scar present on the epigastric region,no Dilated veins are seen.

On palpation:
Abdomen is Soft,tenderness present in epigastric region and there is a mild Rigidity present in the epigastric region.

On auscultation:
 Bowel sounds are heard


Investigations:

CBP
 
X-Ray


LFT:

TB:2.18
DB:0.79
AST:51
ALT:27
ALP:176
TP:7.5
ALB:4.5


RFT
Urea:20
Creatinine:0.9
Na:139
K:3.2
CL:103




Diagnosis:

Acute Pancreatitis

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