26 yr old male patient with abdominal pain

 This is online E-log book to discuss our patients deidentified health data shared after his/her/guardian's signed informed consent .Here we discuss our individual patient's problem through series of inputs from online global community with an aim to solve those patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

A 26yr old male resident of nlg came with chief complaints of pain in abdomen since 2 days and also had episodes of vomiting.

HOPI

pt was apparently asymptomatic 4 days ago then developed abdominal pain at the left upper region which was sudden in onset , nonradiating,progressive dull aching type associated with nausea and vomiting which are non bilious non projectile with food as content

No h/o of fever, loose stools, burning micturition

Not a k/c/o of HTN DM TB asthma epilepsy

PAST HISTORY

He was a k/c/o acute pancreatitis , diagnosed 1 week back and treated at a local hospital.

He was a chronic alcholic but stopped drinking 1month ago.

On admission :

Patient is conscious coherent cooperative 

BP:100/70mmhg

PR: 80

RR:20cpm

Temp:afebrile

Cvs: S1 S2+

RS: BAE+ ,right infrascapular crepts and rt infrascapular wheeze heard.

CNS:NAD

Speech: Normal

REFLEXES:

                                     RT.              LFT

BICEPS.                      ++                ++

TRICEPS.                    ++                ++

SUPINATOR.             ++                ++ 

ANKLE.                     ++                 ++   

KNEE.                        ++                ++

P/A :soft ,non tender

No pallor , icterus, cynosis, clubbing,lympadenopathy.

Apetite:normal

Diet:mixed

Bowel and bladder: regular

Sleep: inadequate

no significant family history

Investigations 




Xray 

11/9/22
13/9/22
14/9/22

Previous discharge history 

Treatment given
10/9/22
Inj. Tramadol 1amp
Inj. Diclofenac
Inj. Pan
Inj.zofer 4mg
Inj. Ciprofloxacin
IVF NS RL DNS @ 75ml/hr

11/9/22
Inj. Pan 40 mg 
Inj. Zofer 4mg
Inj.tramadol 1amp
IVF NS RL DNS @ 75ml/hr
12/9/22
Inj. Tramadol 1amp
Inj. Diclofenac
Inj. Pan 40 mg
Inj.zofer.
Inj. Ciprofloxacin
IVF NS RL DNS @ 75ml/hr
13/9/22
Inj. Tramadol 1amp
Inj. Diclofenac
Inj. Pan 40mg 
Inj.zofer.
Inj. Ciprofloxacin
IVF NS RL DNS @ 75ml/hr
14/9/22
Tab. Tramadol 1amp po/tid
Tab.zofer 4mg po/bd
Tab. Pan 40mg po/od
Inj. Ciprofloxacin 50mg iv/bd


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