40 yr old male with pain abdomen

November 28,2022
This is online E-blog, to discuss our patient de-identified health data shared after taking her 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 the patients clinical problem with current best evidence based input.

I have been a case in order to make my skills better in understanding the "Patient's clinical data analysis". Making a note of all the necessary information like the history of patient's present illness, his medical history, his family history, diagnosis and treatment plan. 

A 40 year old male patient came to OPD with pain in the abdomen. 

History of present illness:
       Patient was apparently asymptomatic 15 years back. He had pain in the left abdomen and was detected as renal canaliculi. PCNL surgery was done. 4 months back he developed pain in the abdomen with yellowish discoloration in the eyes. He was admitted to hospital and conservative treatment was done. One day back he again developed pain in the right hypochondriam. The pain is insidious in  onset and non radiating type. Not associated with vomiting. Associated with low grade intermittent fever with is subsiding on medication. 
History of past illness:
        Patient is a known diabetic since 6 months and is on medication Glycichek.
No history of hypertension, asthama. 
Personal history:
   Patient is married. He is a daily labor. 
Apatite - normal
Diet- mixed
Bowels- normal
Habits - alcohol occasionally. 
Vitals:
Temperature - 98. 4
Pulse - 80 beats /min 
BP - 110/70mmhg 
Respiratory rate- 16 / min
SpO2- 96℅
Investigations: 
Hemogram - normal
Urine examination- 
     Albumin- +
     Sugars- ++++
Fasting blood sugar - 182
Post lunch sugar - 245
Serum lipase - 104
Urea- 32
Creatnine- 0.8
Serum amylase- 831
Liver function tests - 
      Total Bilurubin- 203
       Direct bilurubin - 1.52
       SGOT - 55
       SGPT - 237
       Alkaline phosphatase - 314
       Protiens - 6.4
       Albumin - 3.8
CT scan: 

Diagnosis : Acute pancreatitis
                    Acute cholecystitis


   

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