49 Y/M WITH PAIN ABDOMEN

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

49 year old male came with complaints of abdominal pain since 1 day

HISTORY OF PRESENTING ILLNESS:Patient was apparently asymptomatic 1day back then he developed abdominal pain which was insidious in onset, gradually progressive,radiating to back with no aggrevating and relieving factors.

H/O Vomitings 3 episodes since yesterday night non bilious,non projectile with food and water as contents.

No H/O Fever,Cold and Allergies

PAST HISTORY:

H/O similar complaints 1 year ago

Known Case of DIABETES MELLITUS TYPE 2 Since 1 year on regular medication (GLIMI-M1)

Not a K/C/O HTN,ASTHMA,TB, EPILEPSY,THYROID,CVA,CAD.

FAMILY HISTORY:NOT SIGNIFICANT

PERSONAL HISTORY:

DIET: MIXED

APPETITE:NORMAL

SLEEP: ADEQUATE

BOWEL AND BLADDER: REGULAR

ADDICTIONS: REGULAR ALCOHOL INTAKE SINCE 20 YEARS 90ml per day and STOPPED drinking for 1 year.Later started drinking 1 week ago.

Regular CIGARETTE SMOKER since 20 years 1Pack/day

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS, COHERENT AND COOPERATIVE,Well Oriented to time,place and person.

No pallor,Icterus,cyanosis,clubbing, lymphadenopathy and edema

VITALS:

TEMPERATURE: 98.6°F

BP: 130/70 mm hg

PR: 84 bpm

RR: 17 cpm

SPO2 : 98% at RA

GRBS: 311 mg/dl

SYSTEMIC EXAMINATION:

CVS: S1,S2 HEARD, NO MURMURS

RS: BAE+,NORMAL VESICULAR BREATH SOUNDS HEARD 

PER ABDOMEN:SOFT,NON TENDER,NO ORGANOMEGALY.

CNS:NO FOCAL NEUROLOGICAL DEFICITS

PROVISIONAL DIAGNOSIS:ACUTE PANCREATITIS with k/c/o DM TYPE 2 since 1 year.

INVESTIGATIONS:

TREATMENT:

1.NBM TILL FURTHER ORDERS

2.IV FLUIDS RL,NS @75ml/hr

3.INJ.TRAMADOL 1AMPULE in 100ml NS/IV/SOS

4.INJ.ZOFER 4MG IV TID

5.INJ.PIPTAZ 4.5GM IV STAT

6.INJ.PAN 40MG IV OD

7.INJ.THIAMINE 200MG IV 8TH HRLY