25 year old male patient with acute pancreatitis

Interns-
Dr. Anjali
Dr. Konda Soumya 
Dr. M. Sreedevi
Dr. Mourya 
Dr. K. Shriya Reddy
Dr. Shashikala pgy1
Dr. Shailesh pgy1
Dr. Zain pgy2
Dr. Natasha pgy3
Dr. Praveen Naik Associate professor
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 box is welcome.
25 year old male came with complaints of pain abdomen  in epigastric region since 4 days 
Abdominal distension from 4 days 
Sob since 4 days 
Fever with headache from 4 days 
Low back ache since 2 days 
HOPI
Patient was apparently asymptomatic 4 days back. 
Then he developed fever sudden in onset, gradually progressive associated with chills and rigor subsidied on taking medications. 
H/o Headache along with fever which was diffuse type not associated with vomitings, blurring of vision, diplopia. 
Has abdominal distension since 4 days gradual in onset associated with shortness of breath. 
H/o pain in abdomen since  4 days sudden in onset,intermittent type present in the epigastric region radiating to the back not associated with vomitings. 
No h/o palpitations, giddiness, vomitings,pedal edema, constipation. 
K/c/o alcoholic since 1 and half year (beer). Last drink was on 24/1/21(after which pain started) 
K/c/o tobacco chewer since 1 year 
Not a k/c/o DM, HTN, Epilepsy, Asthma. 
O/E:
Patient is conscious, coherent and co-operative 
Temperature-afebrile on touch
P/A-soft,distensed abdomen 
No tenderness 
No guarding, Rigidity
Rs-Decreased breath sounds in Right Infrascapular area. 
Cvs-s1s2 heard no murmurs 
Jvp normal 
Cns -HMF intact




Provisional diagnosis: Acute Pancreatitis
Rx
1) IV fluids 1 NS, 1 RL, 1DNS over 100ml/hr
2) INJ.PANTOP 40mg IV OD 
3) INJ. TRAMADOL 1 amp in 100ml NS IV OD
4) INJ. OPTINEURON 1 amp in NS IV OD
5) INJ. THIAMINE 1 amp in NS IV OD
6) STRICT I/O CHARTING
7) BP/PR/Spo2 MONITORING

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