A 50 year old male with pain abdomen

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Hi, This is Vijaya Ratna,5th sem medical student.This Elog depicts the patient centered approach to learning. This is an online eLogbook recorded to discuss and comprehend our patient's deidentified health data shared, after taking his/her/guardian's signed informed consent.
**This is an ongoing case.I am in the process of updating and editing this Elog as and when required**

A 50 year old male resident of  nalgonda,maths lecturer by occupation came to OPD with chief complaints of
Abdominal distension since 3 days 
Pain abdomen since 3 days
Vomitings

HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 3days back,then developed pain in the upper abdomen gradually progressive associated with abdominal distension with history of vomiting(non bilious,non projectile,non foul smelling,water or content)
Since 2 days he's been suffering from SOB even on rest.
He has been drinking alcohol and smoking since 20 years occasionally.But from past 15-20 days he's been taking alcohol frequently.He vomits everytime he drinks,which is being observed since 10 years and has gastric problem everytime after consumption of alcohol,for which he is using T.Omeprazole and Rabiprazole.

PAST HISTORY
K/o Hypertension since 4 years
N/k/c/o of DM,TB,CVA,CAD,epilepsy

PERSONAL HISTORY
Occupation - Maths lecturer
Appetite - normal
Diet - Mixed
Regular bowel and bladder movements 
Micturition - Normal
He has no known Allergies
Addictions
Alcohol- Regular (90ml/180ml/day) since 20 years
Tobacco - Smoking since 20 years (8/day)

TREATMENT HISTORY
On Angiosart(T Telma H+T Hydrochlorothiazide)for Hypertension since 4 years.

FAMILY HISTORY 
His brother has been suffering from  pain abdomen since 10 years

GENERAL EXAMINATION
Patient was conscious, coherent, cooperative, well oriented to time, place, person and examined in a well lit room.
VITALS
Temperature - 98.6F
Pulse rate - 101/min
Respiratory rate - 18/min
Blood pressure - 130/90mmHg
SpO2 -99%
GRBS - 155mg/dl

PHYSICAL EXAMINATION
Pallor - Absent
Icterus - Present
Clubbing - Absent
Cynosis - Absent
Lymphadenopathy - Absent
Edema of feet - Absent
Dehydration - No

SYSTEMIC EXAMINATION 
CARDIOVASCULAR SYSTEM
Thrills - No
Cardiac sounds - S1 & S2 heard
Cardiac murmurs - No

RESPIRATORY SYSTEM
Dyspnea - absent
Wheeze - absent 
Position of trachea -central
Vesicular Breath sounds - Normal

PER ABDOMEN
INSPECTION
Distended shaped abdomen 
Movements with respiration- normal
Visible pulsations - No
Engorged veins - No
PALPATION
Tenderness - present(diffuse type)
Liver and spleen - Not palpable
PERCUSSION
Dullness of abdomen - No
AUSCULTATION
No Bowel sounds

CNS 
Level of consciousness - stuporous
Speech - normal
Neck stiffness - No
Kernig's sign - No

INVESTIGATIONS
18/7/2022
HEMOGRAM
COMPLETE URINE EXAMINATION
BLOOD GROUPING 
19/7/2022
RENAL FUNCTION TEST
SERUM LIPASE
SERUM AMYLASE
LIVER FUNCTION TEST
ECG
20/7/2022
ULTRASOUND
PROVISIONAL DIAGNOSIS
Acute Pancreatitis secondary to Alcohol

TREATMENT
OVF(RL & NS)@ 150ml/hr
Inj.PANTOP 40mg/IV/OD
Inj.ZOFER 4 mg/IV/SOS
Inj.TRAMADOL 1 amp in 100ml IV/BD
Inj.THIAMINE 200 mg in 100ml NS
NBM till further orders
Ryle's tube aspiration 4th hourly
Abdominal girth measurement daily
Monitor vitals 4th hourly
Strict I/O charting



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