26 year old male with c/o Abdominal pain and Vomitings

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed 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.
This is the case I have been given :-
 A 26 year old patient cab driver by occupation came to the hospital with c/o abdominal pain around the umbilicus

 CHIEF COMPLAINTS -
 The patient has c/o pain in the abdominal region near the umbilicus
 And c/o vomitings on the day of addmission

 HISTORY OF PRESENT ILLNESS

 The patient was apparently asymptomatic 4 months ago.
Had sudden onset of pain in the same region as now and was diagnosed with pancreatitis

 HISTORY OF PAST ILLNESSES
 Patient was treated for pancreatitis with medication 
No surgery was done
 No h/o DM HTN asthma TB
FAMILY HISTORY
No h/o similar conditions in his family
PERSONAL HISTORY
He is a driver by occupation and had consumed a lot of spicy fast food due to his profession
Appetite has been decreased since 4 months from the onset of pain
Bowel movements normal
No burning micurition
Diet mixed
GENERAL EXAMINATION
 No Pallor/ icterus/ cyanosis/clubbing/lymphadenopathy/edema


INVESTIGATIONS 







ULTRASOUND
ECG -
2D -
Xray- 
Fever charting -

PROVISIONAL DIAGNOSIS -

ACUTE PANCREATITIS 

TREATMENT 

 1) IVF NS RL @100 ML/HR

2) INJ TRAMADOL 1 AMP IN 100ML NS IV/SOS

3) TAB PAN 40 MG PO/OD/BBF

4) TAB ZODER 4 MG PO/SOS 

5) TAB PANCREATO FLAT PO/OD

6) SYP CREMAFFIN PLUS 15 ML PO/HS

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