40year old male with pain abdomen

40 yr old male with pain abdomen

July 30, 2023

CHEIF COMPLAINTS
C/O pain Abdomen since 4 days 

History of Present Illness
Patient was apparently asymptomatic 4days back then developed pain in the left hypochondriac region which is radiating to the right hypochondriac region 
C/O vomiting since 4days, 3 episodes watery in consistency ,non-blood stained, non foul smelling
No C/O fever, decreased urine output, loose stools
H/O Burning micturition since 4days 
C/O SOB, palpitations, orthopnea

PAST HISTORY
No H/O similar complaints in the past 
Not a k/c/o HTN,DM,Asthma,Epilepsy,CAD

TREATMENT HISTORY
Not significant 

PERSONAL HISTORY
Diet - Mixed
Appetite - Normal
Sleep - Normal
Bowel and Bladder movements-Regular
Allergies - None
Addictions-Alcohol addiction since 10 years last consumption was 2 days ago

FAMILY HISTORY
No history of similar complaints in the family

GENERAL EXAMINATION
The patient is conscious,coherent and cooperative; well oriented to time,place and person.
Pallor-absent
Icterus-absent
Clubbing-absent
Cyanosis-absent
Lymphadenopathy-absent
Edema-absent 

VITALS
Temperature - 98.6 F
Blood pressure - 140/90 mmHg
Pulse rate - 85bpm
Respiratory rate - 18cpm

SYSTEMIC EXAMINATION

CVS: 
S1 and S2 heard. 
No addded thrills or murmurs heard

RESPIRATORY SYSTEM:  
Normal vesicular breath sounds heard. 
Bilateral air entry present.

ABDOMEN:
INSPECTION:
shape of abdomen - distended
umbilicus -central
no sinuses
No scars
PALPATION:
Tenderness+ over hypochondriac region
Fluid thrill +
Puddle sign +
PERCUSSION:
No shifting dullness
AUSCULTATION:
Bowel sounds +

CNS:
Conscious and coherent
Normal sensory and motor responses
Speech normal

INVESTIGATIONS
ECG
Ultrasound
X RAY

PROVISIONAL DIAGNOSIS
Acute Pancreatitis ?












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