29 yr old with pain abdomen

A 29 yr old male patient named lingaiah came to the opd with cheif complaints  of 

Pain abdomen since 3 days associated  with tightness of abdomen

Vomitings since 3 days .

 HOPI

Patient is apparently asymptomatic  3 days back then he developed  pain abdome associated  with tightness of abdomen   Vomitings  which is non projectile and non bilious. 

No H/o of fever, body pains , headache ,diarrhea

H/o of outside consumption of food 2 days back

PAST H/O

K/c/o pancreatitis  2018,2020 -2 episodes 

Not a k/c/o diabetes ,HTN, TB,asthama,cvd , epilepsy.

PERSONAL H/o

diet - mixed

Apetite - normal

Bowel ,bladder movements - regular

Sleep - adequate 

Addictions - h/o of smoking stopped 2 yrs back.

FAMILY  H/O

No significant  family h/o

GENERAL  EXAMINATION 

patient is conscious, Cooperative, coherent, oriented to time,  place, person 

Vitals 

Bp 130 /70  , HR 86 ,PR 22, GRBS 125, spo2 98%

No pallor 

No cyanosis

No clubbing

No icterus ,

No edema

No Lymphadenopathy 

SYSTEMIC EXAMINATION 

Cvs

S1 s2 heard no murmurs

Respiratory system

Normal vesicular breath sounds,  no wheeze , no dyspnea , trachea is central

Abdomen

Shape of abd - scaphoid

Tenderness  - present 

No palpable mass, fluid , bruit

No palpable liver  , spleen

P/V , P/R  NORMAL

CNS

Patient is conscious , speech normal, no meningeal signs

Cranial nerve ,Sensory, motor examination ,reflexes , gait normal , no cerebral signs

PROVISIONAL DIAGNOSIS 

acute on chronic pancreatitis 

INVESTIGATIONS 

CUE , CBP ,serum amylase ,serum lipase,ECG,HIV ,HBsAg,HIV .










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