45M with pain abdomen and vomitings with k/c/o DM & HTN.

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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.



45M presented to casuality with c/o Pain abdomen and vomitings since yesterday morning.

Pt was apparently asymptomatic 10years back where he developed epigastric burning sensation followed by vomiting. Pain aggrevated after food intake and relieved with medication. On UGIE they were told that ?ulcer has began now and he should stop alcohol and tobacco chewing.
Then 3 years back patient met with an accident (he was under alcohol influence) developed injuries and hospitalised, where he was first diagnosed with Diabetes and started on OHAs currently on Tab. Glimepride 2mg, tab. Metformin 500mg od, tab. Voglibose 0.2mg od. (As a fixed combination)
1 year back patient developed complaints similar to now as pain abdomen and vomitings and was diagnosed with Acute pancreatitis, Lt renal calculi with DENOVO HTN and prescribed tab. Benidipine 8mg od.
Now patient presented with pain abdomen localised to umbilicus and lt lumbar region Associated with nausea and vomitings 8 episodes food particles as contents, no bloody vomitings.
Known alcoholic since 20years initially started with friends and eventually developed dependance.
Tobacco chewer since 20yrs stopped since 10years.

O/E : 
Pt C/C/C
Oriented to time place person
BP : 140/100mmhg
PR : 76bpm
RR : 24cpm
GRBS : 168mg/dl

General examination : 
Pt moderately built and nourished.
No pallor, icterus, cyanosis and clubbing.
Shape of abdomen is obese.




Systemic examination : 

CVS: S1, S2 Heard, No JVP, Apex beat left 5th ICS mid clavicular line.

RS: BAE+, NVBS heard.

P/A : soft, non distended.
           Diffuse tenderness is present in all zone of abdomen. All quadrants are moving accordingly.

CNS : NAD.


ECG :


CXR-PA





USG ABDOMEN : 


Diagnosis : left renal colic 2to Lt renal calculi with DM & HTN.

Rx: 
Day1 : 

IVF 2 NS & 2 RL @ 100ml/hr
Inj. Zofer 4mg IV TID
Inj. Tramadol 1amp in 100ml NS IV BD
Inj. PAN 40mg iv OD
Inj. Ketorolac 1amp IM sos
Inj. Drotin 1amp IM sos
Tab. Benidipine 8mg po od
Tab. Triomet po od
Bp/PR/TEMP monitoring 4th hourly
GRBS charting 6th hourly.




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