A 40 year old male with pain abdomen and constipation.

 This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING!

This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.

A 40 year old male came with chief complaints of pain abdomen since 3 days,which is burning type,which is non - radiating.No history of vomitings,loose stools and fever.Constipation since 4 days.

Chronic alcoholic since 20 years,last binge was taken 4 days back.He was a known case of acute intestinal pancreatitis,1-1/2 year back,then stopped drinking at that time and again he started drinking alcohol 2 months back,then he developed pain abdomen 3 days back.

Past history-not a k/c/o dm/htn/asthma/tb/epilepsy/cad.

Personal history- diet- mixed,

Appetite-lost since 4 days,

Bowel- constipation since 4 days,

Micturition- normal 

Addictions-regular since 20 years 

Tobacco smoking-since 20 years-1 pack beedis/day.

Vitals- 

Temperature - afebrile 

Pr-68/min 

Rr-18/ min 

Bp-130/70 mm Hg 

Spo2-98% at RA 

General examination-

Patient is conscious, coherent and cooperative 

There is no pallor,icterus,cyanosis,clubbing, lymphadenopathy,oedema.

Systemic Examination-

Cvs-s1,s 2 heard.

No added sounds 

Resp- BAE +

NVBS heard.

Per abdomen- tenderness felt in epigastrium.

Bowel sounds are sluggish 



Cns- NFND 

Investigations- 

Haemogram 


Serum amylase

Serum lipase 


Liver function test- 


Psychiatry referral was done in view of Aggressive behaviour and alcohol dependence.








Ultrasound-No sonological abnormality detected. 


Review ultrasound- Diffusely altered echotexture of pancreas noted(head and body only),

No evidence of peripancreatic collection. 



Provisional Diagnosis-Acute pancreatitis secondary to alcohol.

Treatment given- 

NBM,

Inj.pan 40 mg/iv/od 

Inj.zofer 4 mg/iv/tid 

Inj.tramadol 1 amp in 100 ml NS, IV/BD 

Inj.thiamine 1 amp in 100 ml NS,IV/TID 

Inj.optineuron 1 amp in 100 ml NS,IV/TID 

IV fluids-NS,RL,DNS @ 100 ml/hr-continous infusion. 

Strict I/O charting.

Bp/pr/temp/spO2 monitoring.






















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