General Medicine Case

 August 23,2021

This is online e-log book to discuss for patients de-identified health data shared after taking his/guardian sign informed consent

Here we discuss our individual patients problem through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best based inputs

Date of admission:16-08-2021

A 45 yeard old male,who is an industrial worker,presented to the opd with

Chief compliant of: pain in the upper abdomen. Pain gets severe on alcohol consumption

HISTORY OF PRESENT ILLNESS: 

•Patient was apparently asymptomatic/normal 5yrs back when he noted upper abdominal pain 

•Insidious in onset which gradually progressed

•Throbbing type of pain

•7 days back he developed upper abdominal pain

•Followed by constipation

•Painful gait(due to weight being barred by left leg)

•Also suffering from headache 

•No swelling of abdomen

•History of Weight loss 

• Excessive sweating


PAST HISTORY

•5 years back he was diagnosed with same abdominal pain due to alcohol consumption 

• No history of trauma 

•No history of epilepsy

• Known patient of diabetes mellitus from 2yrs

• Has being prescribed insulin since 6months 

• History of pulmonary koch 2yrs back

• No hypertension-CKD

•No asthma 

•No history of surgeries 

•No history of previous radiation exposure 

PERSONAL HISTORY 

•Diet:Mixed diet 

•Appetite: normal 

•Sleep: Inadequate

•Bowel and bladder movements:       constipated

•Addictions: Alcoholic since 15years

FAMILY HISTORY 

•No history of similar complaints in the family members 

TREATMENT HISTORY

•No history of drug allergy 

GENERAL EXAMINATION 

•Patient is coherent co-operative well oriented normal built abnormal gait and malnourished

• No pallor 

•No icterus 

• No cyanosis 

•No lymadenopathy 

•No pedal edema 

VITALS 

•Temperature:98.5f 

•Blood pressure:100/70mmHg 

• PR: 82PPM~ Normal 

•RR: 19CPM

SYSTEMIC EXAMINATION

• CVS- S1 S2 sounds are heard 

•CNS- normal

•No abnormality in muscle 

•Abdomen is tender 

PROVISIONAL DIAGNOSIS 

•This is a case of chronic pancreatitis with diabetic ketoacidosis 

INVESTIGATIONS  








TREATMENT 

• Inj. Tramadol 1amp in 100ml NS/ IV/ BD 

•Inj. Pantop 40mg IV/BD 

•Inj. Thiamine 1amp in 100ml NS/IV/BD 

•Syrup cremafine plus 15ml/PO/HS

• Insulin 5units TDS






































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