A 67 year old male with chief complaints of abdomen since 3 months

 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 E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comments.

Chief complaints:

Pain in upper abdomen since 3 months

Difficulty in taking food since 1 month.

History of presenting illness:

Patient was apparently asymptomatic 3 months back then he complained of abdominal pain on right lumbar region which was insidious in onset  gradually progressive, squeezing type of pain , continuous not related to food intake,not associated with regurgitation , vomiting, Malena,hematemesis,nausea.

Pain aggravated on cough, inspiration and relieved on lying down right side.

Past history:

No similar complaints in the past.

Not a known case of dm,HTN,asthma,Tb, epilepsy,CAD

Family history:No relevant family history

Personal history:

Appetite:normal

Bowel and bladder: regular

Diet:mixed

Sleep: adequate

Addictions:

Daily intake of alcohol 180ml since 30 years

40 beedis per day since 50 years 

Allergies:nil



GENERAL EXAMINATION:-
Patient is conscious, coherent, cooperative and well oriented to time , place and person, moderately built and under nourished.
Pallor is present 
No icterus 
No cyanosis
No clubbing
No lymphadenopathy 
No edema.





Vitals:

HR:66bpm

BP:130/80

RR:17cycles per minute

Temp:98.8F

Systemic examination:

Abdominal examination:

No scars

Pigmentation present on the umbilical region 

Shape of the abdomen: scaphoid

Tenderness : present on right hypochondrium right lumbar region

Palpable mass: absent

Spleen:not palpable

Liver:not palpable


CVS:S1,S2 heard,no murmur


RESPIRATORY SYSTEM:


trachea central in position


Normal vesicular breath sounds heard


BAE ++

CNS examination:

Speech: normal

Reflexes: normal

Finger nose coordination: present

Kneel heel coordination: present

INVESTIGATIONS:

HEMOGRAM:

Blood urea:
Liver function test:
Serum amylase:


Serum creatinine 


Ultrasound
Provisional diagnosis: chronic pancreatitis
Treatment:
Inj.tramadol
Tab.ultracet
Tab.pan



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