Akshara kruthi 40 

Hi,I am G.Akshara kruthi 5th sem medical student.This is an online elog book to discuss our patients de-identified health data shared after taking his/her/guardians signed informed consent.Here we discuss our individual patients 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 reflects my patient centered online learning portfolia 

Case details :

37 years old male patient resident of nalgonda 
Auto driver by occupation came to the causality
 With chief complaints of 
  * Epigastric pain since 5 days 
  *Fever with chills since 2 days  
  *Reddish discoloration of urine since 2 days 

    History of present illness :

Patient was asymptomatic 6 mnts back then he developed stomach pain and came to Kims narketpally which was revealed by medication 
Then he developed pain in upper abdomen since 5  days which is intermittent associated with food intake ,non radiating , twisting type , aggravated with food intake , relieved partial with medication .no H/o vomiting ,loss of appetite.H/O fever since 2days , intermittent  associated with chills ,no aggregating factors, relieved with medication.

Past history 

K/c/o - Dm type 2 since  6 months -
K/c/ o - Hypertension since 6 months
K/c/o - acute pancreatitis in Feb 2022 

Personal history 

Married 
Occupation : Auto driver 
Appetite:normal
Non veg
Bowels:regular
Micturition:normal
No known Allergies
Addictions
Alcoholic 90-180 ml daily since 15 yrs 
Ciggerate smoker since 10 yrs 4-5 /day
Gutka since 10 yrs 

Treatment history 

Tab .Metformin 500 mg po OD since 6 mnts 
Tab .telmisartan 20mg po OD since 6 mnts 
Tab.rabeprazole and tab domperidone for  pancreatitis 
Family history 
No such significant history 


PHYSICAL EXAMINATION
A. GENERAL EXAMINATION
Patient was conscious, coherent, co- operative. Well oriented to time, place and person.

 No pallor
No icterus
No clubbing
No cyanosis
No lymphadenopathy 
No edema
No malnutrition
No dehydration

VITALS
TEMPERATURE-Afebrile 
BP-160/110mm of hg
PR :78 BPM, regular 
GRBS : 220mg%
Spo2:98%
B. SYSTEMIC EXAMINATION
Patient was examined in a well lit room after taking the proper concern. 

CARDIOVASCULAR SYSTEM
S1, S2 +ve. 
No murmers

RESPIRATORY SYSTEM
BAE +ve
Normal vesicular breathe sounds heard

PER ABDOMEN
Soft ,Epigastric tenderness 
Not palpable 

CENTRAL NERVOUS SYSTEM
Conscious
Normal speech
No neck stiffness
No kernings sign
Cranial, motor, sensory systems :NAD

REFLEXES
Normal reflexes


INVESTIGATIONS
CBP:
Hb-19. 1g/dl
TLC-8500 Cells/cu.mm
Platelet count-1,75/microliter.
PCV :54.7
RBC:6.32

CUE:
Blood urea:29mg/dl
Serum creatinine-0. 8mg/dl
Na+:136meq/l
K+:3.7meq/l
Cl-:102meq/l
Serum lipase:  42U/l 
Serum amylase :25 U/l

LFT:
Total bilirubin:2.55mg/dl
Direct bilirubin:1.88mg/dl
RBS
122mg%
ECG :
Hemogram:

Serology 

RBS
Serology 


Peripheral smear :



Provisional diagnosis 

     Acute pancreatitis 

Treatment

NBM till further order 
Inj.Thaimine 200 mg in 100 ml NS Iv/OD 
Inj.pan 80 mg in 500 ml NS 100 ml / hr stat 
Tab . telmisartan 20 mg od po 
Inj.HAI sc TID according to GRBS 
GRBS 6 th hrly beprazole and tab domperidone OD for acute

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