A 55 year old male patient with Abdomen pain

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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