Acute Pancreatitis
CASE OF A 45 YEAR OLD MALE WITH C/O ABDOMINAL PAIN
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 Is The Case I Have Been Given :
A 45 year old male driver by occupation came to the opd with
C/o vomitings since one day
C/o pain abdomen since one day
Patient was apparently asymptomatic 1 day back and then suddenly developed vomiting 10 episodes yesterday containing food particles, non bilious , non projectile for which he went to local hospital and was given IV fluids and then developed pain abdomen in the epigastric region , around the umbilicus.Pain aggravates on leaning back from bending position , associated with sob , pain aggravates on taking food.
He had 1 episode of vomiting today morning,watery,non bilious,non projectile.
No H/o similar similar complaints in the past
N/K/ C /O HTN,DM,TB,EPILEPSY,ASTHMA,THYROID
H/o chronic alcoholism - Started drinking from 15 years of age daily 90 ml of whiskey for 20 years and then increased his consumption to 180-200 ml since 2 years
H/o tobacco chewing since 20 years
H/o smoking cigarettes one daily for 18 years
Vitals @ Admission :
Temp: 98.6F
BP:120/70 mmHg
HR:80 bpm
RR: 18 cpm
GRBS: 103 mg/dL
SpO2: 98% on RA
General Examination:
Pt is c/c/c
No Pallor/Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
Thyroid normal
Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: NVBS, BAE+
CNS - NAD
PA - Soft , Tenderness +
Pain abdomen in the epigastric quadrant and around the umbilicus
Investigations and Reports -
19/05/2022
SERUM ELECTROLYTES- NA - 137 mEq/L
K - 4.3 mEq/L
Cl - 99 mEq/L
SERUM CREATININE - 0.8 mg/dl
SERUM LIPASE - 670 U/L
SERUM AMYLASE - 566 U/L
20/05/2022
Psychiatry Refferal Done -
22-05-2022
PROVISIONAL DIAGNOSIS -
ACUTE PANCREATITIS
TREATMENT -
1) NBM Till further orders
2)IVF NS RL DNS } 125 ml/hr
3)INJ TRAMADOL 50 mg in 100 NS/TID
4)INJ PAN 40mg IV/OD
5)INJ THIAMINE in 100 NS IV/TID
DAY1
SOAP NOTES- AMC- BED 2 - DAY
DOA: 20/05/2022
Pt c/o pain abdomen- Epigastric and Around the Umblicus
Vitals
Temp: 98.6
BP:120/70 mmH
HR:80 bp
RR: 18 cp
GRBS: 103 mg/d
SpO2: 98% on R
General Examinatio
Pt is C/C/C
No Pallor/Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edem
Thyroid normal
Systemic Examination -
CVS: S1S2 heard, No murmur
RS: NVBS, BAE +
CNS: NAD
P/A: Pain abdomen in Epigastrium and around the Umblicus
Acute Pancreatitis
P1) NBM Till further orders
2)IVF NS RL DNS } 125 ml/
3)INJ TRAMADOL 50 mg in 100 NS/T
4)INJ PAN 40mg IV/
5)INJ THIAMINE in 100 NS IV/TID
Comments
Post a Comment