55 yr old male with pain abdomen

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.

Here is a case i have seen:
55 year old male patient came with complaints of fever since 10 days, pain abdomen and vomitings since today morning. patient was apparently alright 10 days back then he had complaints of high grade fever, continuous associated with chills and rigors relieved with medication ,no diurnal variation. got admitted for 4 days in private hospital and got discharged. From today morning patient is complaining of pain in the epigastrium and right iliac fossa, associated with vomitings vomitings 2episodes of billious vomitings  and 10 to 15 episodes with water consistency and non projective

history of similarity episodes 1 year back

 patient is chronic alcoholic till one year back stopped after the similar episode he is a known case of diabetes since 8 years on glimi M1, 
Personal history: 
Appetite: normal
Bowels: regular 
Bladder- normal micturition
Family history:
No history of DM, HTN CAD, CVA, aasthma   in the family
General examination: patient is conscious, coherent, cooperative 
Pallor is seen.
No icterus, cyanosis, clubbing,lymphadenopathy, edema
Vitals:
Temperature: 98F
Pulse: 86bpm
Respiratory rate: 16/ min
Bp: 130/80mm hg
Spo2: 98% at RA
GRBS: 314 mg%
Systemic examination: 
Cvs: S1 S2 heard no additional sounds or murmurs
Rs: NVBS
P/A tenderness+ diffuse (more at epigastrium)
gaurding +
Cns: higher mental functions intact 
Provisional diagnosis: 
?acute pancreatitis
? DKA
GRBS CHARTING 
Investigations 
HEMOGRAM
LFT
RFT
URINE FOR KETONE BODIES 
HbA1c
SERUM LIPASE
SERUM AMYLASE
FASTING BLOOD SUGAR
SERUM POTASSIUM 
HIV 1&2
HBSAg rapid
ANTI HCV 
USG ABDOMEN 
X ray erect abdomen 
chest x ray PA view 
ECG
CLINICAL IMAGES 
TREATMENT GIVEN 
Day 1 
1. NBM TILL FURTHER ORDERS 
2.IVF 2 NS @75ML PER HR
3. INJ PAN 40 MG IV/OD
4. INI TRAMADOL 1 AMP IN 100 ML NS IV/OD
5.INJ ZOFER 4 MG IV/ TID
6.RYLE'S TUBE INSERTED 
7. I/O CHARTING 
8.TEMP ,PULSE,BP,SPO2 CHARTING 4 TH HRLY 
GRBS CHARTING 6 TH HRLY. 
Day 2
1.IVF 2 NS @100 ML/HR
2.ALLOW ORAL LIQUID DIET 
3.INJ PANTOP 40 MG /IV/OD 
4.INJ ZOFER 4 MH /IV/TID
5.INJ TRAMADOL 1 AMP IN 100ML NS IV SOS
6. INJ HAI /SC 
8AM  2PM  8 PM  AFTER INFORMING GRBS 
7. GRBS CHARTING 4 TH HRLY 
8. STRICT I/O CHARTING 
9. TEMP CHARTING 4 TH HRLY 
10.BP/PR/SPO2 CHARTING 4 TH HRLY 
11.INJ CEFTRIAXONE 1GM/IV/BD 

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