32yr Male abdominal pain/ vomitings


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 comment . 


Patient presented with chief complaints of abdomen pain and vomitings (4 episodes)


History of present illness:
Patient was apparently asymptomatic and had pain in the epigastric and right hypochondrium the pain was aggrevating on walking,
He had vomitings 4 episodes non bilious and non projectile with food and water as contents 
No H/O of fever, trauma
H/O alochol intake on 28/8/23


PAST HISTORY:
K/C/O Diabetes mellitus since 3yrs on medication 
Not a K/C/O HTN,asthma, epilepsy, Tuberculosis 
No significant past surgical history

TREATMENT HISTORY:
Using metformin since 3yrs for DM

 PERSONAL HISTORY:
Diet- mixed
Sleep-adequate
Bowel and bladder: hard stools
Drinks alochol daily 250ml
Doesn't smoke 

FAMILY HISTORY:
Not significant 

GENERAL EXAMINATION
BP:130/90mmHg
RR-18/min
PULSE-70
Temp- afebrile
PALLOR-No
ICTERUS-No
CLUBBING-No
KOLINYCHIA-No
LYMPHEDENOPATHY-No
EDEMA-No


SYSTEMIC EXAMINATION:
CVS- S1 S2 heard 
Respiratory -
No wheeze
No dyspnoea
Trachea Central 
Vesicular breath sounds
CNS- No neurological focal deficit 
Per abdomen:
Local examination
Inspection:
Abdomen is obese
All quadrants are equally moving 
No scars
No engorged veins
No visible pulsations 
Palpation:
Tenderness present over left hypochondric,epigastric
Left lumbar,left hypogastric region 
Spleen enlargement

Auscultation
Bowel sounds present






















ULTRASOUND



Provisional diagnosis:
?Acute pancreatitis 
?Acute gastritis 




































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