a case of 26 yr old male

This is 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 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 26 yr old male resident of nalgonda came with chief complaints of pain in abdomen since Friday 1am and had  also had2 episodes of vomiting.
HOPI
Pt was apparently asymptomatic  4 days ago then he developed abdominal pain at the left upper region which was sudden in onset, nonradiating, progressive dull aching type associated with nausea and vomiting which were non bilious non projectile with food as content.
No h/o of fever,  loose stools, burning micrurition 
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 alcoholic but stopped drinking 1month ago.


On admission.
Patient is conscious coherent cooperative 
BP: 100/70mmhg
PR:80
RR: 20 cpm
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, cyanosis, clubbing, and lymphadenopathy 

Appetite:normal
Diet:mixed
Bowel and bladder:regular 
Sleep:  not adequate 
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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