A CASE OF CHRONIC PANCREATITIS

MEDICINE CASE DISCUSSION 

This is an E-log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient 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 comments in comment box are most welcomed .

I have been given this case, in an attempt to solve and understand the topic of "Patient's clinical data analysis”. This has helped me develop my competency in reading and comprehending clinical data including history taking, clinical findings and investigations. The goal is to come up with a diagnosis and treatment plan.  

PAVITRA BALDAWA  

ROLL NUMBER -104

 17th November 2021

CASE DISCUSSION
A   year old male patient painter by occupation came to the medicine OPD on 16 th November 2021 at 9pm

CHIEF COMPLAINS:

The patient came to the medicine OPD with chief complains of severe abdominal pain since 2 days.

HISTORY OF PRESENTING ILLNESS:

The patient was apparently assymtomatic 2 days back when he developed abdominal pain which was sudden in onset non progressive squeezing type of intermittent  pain in the epigastic region which is triggered with drinking alcohol and pain relief on saline infusion .
The pain reduces on bending down.The pain is not radiating or migrating to back.
It is associated with nausea and vomiting  1 episode  which was non projectile ,bilious with food contents.
It is associated with loose stools , 5 episodes for 1 day brown to yellow in colour and associated with flatulence.
Not associated with fever.

PAST HISTORY: Similar complains in the past since  3 months , he had 3 similar episodes for which he was admitted in the hospital and treated with saline all the 3 times.
History of blood transfusion - 23 years ago
He is diagnosed with hypertension 1 week back and is irregular with medicine.
No history of diabetes , epilepsy,and tuberculosis.

PERSONAL HISTORY:
Diet-mixed
Appetite- normal
Sleep-adequate
Bowel and bladder- burning micturation for 1 day( yesterday) and loose stools for 1 day
Addictions-
He drinks about 90 ml everyday since the last 10 years but stopped drinking 3 months back 
He had a alcohol binge last night and had abdominal pain.
No other addictions

FAMILY HISTORY: Insignificant

GENERAL EXAMINATION:
The patient is conscious coherent and cooperative
He is well oriented to time ,place and person.

VITALS:
Heart rate:80bpm
Blood pressure:130/80mmhg
Respiratory rate: 14 cpm
Temperature: afebrile

Pallor:present
Icterus:absent
Cyanosis: absent
Clubbing: absent
Lymphadenopathy:absent
Edema:absent


SYSTEMIC EXAMINATION:








INVESTIGATIONS




PROVISIONAL DIAGNOSIS:
Chronic pancreatitis with alcoholic gastritis


TREATMENT:




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