A 26yrs old male with acute pancreatitis

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. 

Date of admission: 23/06/22 

CHIEF COMPLAINT: 

A 26 year old male patient, car driver by occupation, came to the opd with chief complaints of 

  • Abdominal pain and
  • Vomitings since 5 days 
HISTORY OF PRESENTING ILLNESS: 

Patient was apparently asymptomatic 4 months back, then he started developing abdominal pain after taking food associated with vomitings ( as he took alcohol regularly for 1 week) for which he was admitted in the hospital and was diagnosed with acute pancreatitis. He was fine after he started using the medication.

Patient ,then started consumption of toddy regularly, 5 days back he developed abdominal pain ( in right hypochondriac epigastric region, not relieved by medication) associated with vomitings ( 3 episodes, non blood tinged, bilious) 

No h/o fever, burning micturition, cough, cold, SOB, orthopnea 

HISTORY OF PAST ILLNESS: 

Not a k/c/o DM, HTN, CAD, TB, asthma 

TREATMENT HISTORY:

Patient was on medication for Acute pancreatitis

No treatment history of DM, Hypertension, Asthma etc 

PERSONAL HISTORY:

  • Single 
  • Occupation: car driver 
  • Appetite- normal 
  • Having mixed diet( Non vegetarian) 
  • Bowels- regular
  • Micturition- normal
  • Alcohol intake- was present until 4 months back, then started consumption of toddy regularly. 
  • No habit of smoking 
  • No other habits/ addictions 

GENERAL EXAMINATION:

Patient is conscious.

Absence of pallor, Icterus, Clubbing, Cyanosis, Pedal edema, Lymphadenopathy.

VITALS:

1.Temperature: 99 F

2.Pulse rate: 78 beats per min

3.Respiratory rate: 16 cycles per min 

4.BP: 110/70 mm Hg

5.SpO2: 96% @ Room air 

6.GRBS: 144mg % 

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

  • S1, S2 heard
  • No thrills, No murmurs

RESPIRATORY SYSTEM:

  • Normal vesicular breath sounds
  • Position of trachea is central
  • Dyspnea is absent 
  • No wheeze

EXAMINATION OF ABDOMEN:

  • Shape- scaphoid
  • tenderness- present 
  • No palpable pass
  • Normal hernial orifices 
  • No free fluid
  • No Bruits
  • Liver is not palpable
  • spleen is not palpable
  • Bowel sounds heard
                


CENTRAL NERVOUS SYSTEM:

  • Patient is conscious 
  • Speech is normal 
  • No focal neurological defect
PROVISIONAL DIAGNOSIS:

 ACUTE PANCREATITIS 

INVESTIGATIONS: 
       
                         
                                                                   ECG 

Ultrasound report 


Fever chart 

2D echo 


TREATMENT: 

Treatment on 23/06/22: 

1. IVF RL 
          NS 100ml/hr 
2. INJ. TRAMADOL 50mg in 100ml NS/IV/BD 
3. INJ. PAN 40mg IV/OD 
4. INJ. ZOFER 4mg/IV/TID 
5. STRICT I/O CHARTING 

Treatment on 24/06/22:

1. NBM till further orders 
2.  IVF RL 
          NS 100ml/hr 
3. INJ. TRAMADOL 50mg in 100ml NS/IV/BD 
4. INJ. PAN 40mg IV/OD 
5. INJ. ZOFER 4mg/IV/TID 
6. STRICT I/O CHARTING 
7. T. PANCREO FLAT PO/OD 

Treatment on 25/06/22: 

1. NBM till further orders 
2.  IVF RL 
          NS 100ml/hr 
3. INJ. TRAMADOL 50mg in 100ml NS/IV/BD 
4. INJ. PAN 40mg IV/OD 
5. INJ. ZOFER 4mg/IV/TID 
6. STRICT I/O CHARTING 
7. T. PANCREO FLAT PO/OD 

Treatment on 26/02/22:

1. Allowing liquid diet 
2.  IVF RL 
          NS 100ml/hr 
3. INJ. TRAMADOL 50mg in 100ml NS/IV/BD 
4. INJ. PAN 40mg IV/OD 
5. INJ. ZOFER 4mg/IV/TID 
6. STRICT I/O CHARTING 
7. T. PANCREO FLAT PO/OD 

Treatment on 27/02/22: 

1. Liquid diet 
2.  IVF RL 
          NS 100ml/hr 
3. INJ. TRAMADOL 50mg in 100ml NS/IV/BD 
4. INJ. PAN 40mg IV/OD 
5. INJ. ZOFER 4mg/IV/TID 
6. STRICT I/O CHARTING 
7. T. PANCREO FLAT PO/OD 






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