SHRUTHI ARUKONDA 02

 GENERAL MEDICINE. 


24 July ,2021. 

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.


            CASE REPORT 

A 26 year old male who is a car driver by profession presented with chief complaints of pain abdomen since yesterday.  

CHEIF COMPLAINTS : 

Pain abdomen since yesterday (epigastric and right and left hypochondriac pain) associated with 2 episodes of vomitings (bilious).  

HISTORY OF PRESENT ILLNESS : 

  • Patient was asymptomatic until 4 months back and consumed alcohol daily for a week, after which he developed a pain abdomen associated with vomitings for which he was admitted in the hospital for a week. 
  • Diagnosed with acute pancreatitis.
  • Was under medication and the pain has subsided, due which he was discharged.  
  • Recently, he started consuming toddy regularly due to which he had a pain abdomen which started in the epigastric region associated with 2 episodes of vomitings which are bilious and non blood tinged.  

HISTORY OF PAST ILLNESS : 
 
N/k/c/o DM, BP, CKD, CHF, Epilepsy. 


TREATMENT HISTORY: 

Nothing significant 

PERSONAL HISTORY : 

Appetite: decreased 
Non veg: occasionally. 
Sleep: adequate 
Alcohol : toddy occasionally 
Non smoker.  

FAMILY HISTORY: 

Nothing significant.  


PHYSICAL EXAMINATION: 

GENERAL EXAMINATION:  

No signs of pallor, cyanosis, icterus, edema, lymphadenopathy. 

VITALS: 

Temp : 99 F
Pulse rate: 78/min 
Respiratory rate: 16/min
BP: 110/70
Spo2: 96%
GRBS:144mg% 


SYSTEMIC EXAMINATION: 

CVS: 

Thrills: no  
Cardiac sounds : S1+ S2+ 
Cardiac murmurs : no 

RESPIRATORY SYSTEM: 

Dyspnoea: no 
Wheeze: no 
Position of trachea: central 
Breath sounds: vesicular 

ABDOMEN: 

Shape : obese 
Palpable mass: no
Liver and spleen : not palpable 
Free fluid: no 
Bowel sounds : yes 

CENTRAL NERVOUS SYSTEM: 

Normal.  

INVESTIGATIONS : 

1. Ultrasound. : 





2. 2D ECHO: 




3. ECG: 



4. X- RAY: 


5: serum amylase: 
















Temperature chart : 




Clinical images: 








Provisional diagnosis: acute pancreatitis.  





























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