26 Year Male with Recurrent Acute Pancreatitis

 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 patients clinical problems with collective current based inputs.


Patient is a 26 year old male, car driver by occupation came to the casualty at 1am with complaints of : 

Cheif complaints:

  •Pain abdomen since 1 day

  •4-5 episodes of vomitings


History of presenting illness


Patient was aymptomatic 6 months back. Then he developed pain abdomen not associated with vomitings not admitted to PE hospital. Subsided on taking medication (augmentin, Tramadol) 


Now today at 1am the patient developed pain abdomen sudden in onset and associated with 2 episodes of vomitings which were bilious. 


Had similar complaints in the past around 12 years back. 


History of past illness


N/K/C/O DM,HTN,TB,thyroid disorders,epilepsy


Personal History


Married 


Car driver by occupation 


Diet: mixed 


Appetite: lost


Bowel bladder moments: regular


Addictions : Chronic alcoholic, stopped 1 month back. 


Family history


Not significant


On examination


Pt is conscious,coherent and cooperative well oriented to time,place,person 


No signs of pallor,icterus,clubbing,cyanosis,lymphadenopathy,pedal oedema 



Vitals


Temp:98.6°F


PR: 82


Rr: 16/ min


Bp:120/70 mm Hg. 


Spo2: 98%


GRBS:102mg%


Systemic examination


CVS: S1,S2 heard, no murmurs heard 


Resp: BAE +


CNS :NAD 


Abdomen: 

Soft, mild tenderness in epigastrium & left hypochondrium no guarding, non ? Bs +



Investigations:


HCV, HIV , HbsAg : negative

Blood Urea : 14mg/dl

Sr. Creatinine: 0.8 mg/dl

CRP : 2.4 mg/dl 


FBS: 86 mg/dl


Blood group : A+ 


Hemogram 


Sr. Electrolytes 


Provisional diagnosis: Acute Pancreatitis


Treatment History 


Day 1 


NBM TIL FURTHER ORDERS


• INJ TRAMADOL IN 100ML NS TID 


• INJ PAN 40 mg OP IV


•INJ ZOFER 4mg IV 


• INJ CIPROFLOXACIN 500mg IV BD 


• IV fluids NS /RL / DMS (@75 ml/min)


 GRBS -every 6th hourly 


BP every 4th hourly 


Day 2 


• INJ TRAMADOL 1amp IN 100ML NS TID 


• INJ PAN 40 mg OP IV


•INJ ZOFER 4mg IV 


• INJ CIPROFLOXACIN 500mg IV BD 


• IV fluids NS /RL / DMS (@75 ml/min)


 GRBS -every 6th hourly 


BP every 4th hourly 


Day 3 


• INJ TRAMADOL IN 100ML NS TID 


• INJ PAN 40 mg OP IV


•INJ ZOFER 4mg IV 


• INJ CIPROFLOXACIN 500mg IV BD 


• IV fluids NS /RL / DMS (@75 ml/min)


 GRBS -every 6th hourly 


BP every 4th hourly 


Patient discharged on day 4 

Comments

Post a Comment

Popular posts from this blog

60M with CKD and HTN

Image
 This is an a 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 This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted A 60 year old male, who is a resident of Nalgonda ,farmer by occupation came with    Chief complaints -Pedal edema since 3 months -shortness of breath since 20 days - decreased  urine output since 15 days History of presenting illness The patient was apparently asymptomatic 3 months back then
Read more

30M with involuntary movements of hands,tingling in upper limbs

Image
 This is an a 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 This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. A 30 year old male came to general medicine opd with   Chief complaints:   Involuntary movements of hands and tingling and numbness in upper limbs and abdomen since 1 day   History of presenting illness :  Patient was apparently asymptomatic 20 days back then He developed fever insidious in
Read more

A case of 57 year,Male with Giddiness , difficulty in walking swaying to right

  92 Sneha Nadipi 5th semester  This is 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 patients clinical problems with collective current best evidence based inputs. *️⃣CASE SENERIO: 🌡CHIEF COMPLAINTS:  Giddiness since 4 days Difficulty in walking since 4 days  Swaying to right since 4 days 🌡HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 5 days back and then developed pain and swelling of bilateral lateral malleolus for which he visited local RMP for which he received an injection (unknown) followed by which he developed excessive sweating and next day he developed excessive sweating and giddiness and difficulty to walk associated with swaying to right for which  he went to local hospital and CT was done and medication were given and
Read more