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 comments on comment box is welcome.
I would like to thank Dr. Raveen sir and Dr. Kranthi ma'am for providing me the case details.
Case History :
A 29 year old male patient presented to the casualty on 10th June with
Chief Complaints :
1. Pain abdomen since morning
2. Vomiting since morning
History of Presenting Illness :
Patient was apparently asymptomatic 3 years back, then he was diagnosed with Acute Pancreatitis in 2018 and there was a 2nd episode in March, 2020.
On the day of admission, the patient had a heavy meal in the morning after which he developed pain abdomen which was sudden in onset, gradually progressive, non radiating and has no aggravating or relieving factors. There is also history of vomiting which was 2 episodes since morning and 3 episodes after presentation. The vomiting was non-bilious and non-projectile.
History of Past Illness :
The patient is a known case of Pancreatitis with an history of 2 episodes in 2018 and 2020.
He is not a known case of Type 2 Diabetes mellitus, Hypertension, Asthma, Tuberculosis, Epilepsy.
Personal History :
Diet : Mixed
Appetite : Decreased
Bowels : Regular
Micturition : Normal
Addictions : Rebound drunker since 2020; History of alcohol intake since 3 years with a frequency of 3-4 times per week
Allergies : None
Family History :
There is no significant family history.
General Examination :
The examination was done after obtaining informed consent in a well lit room.
Patient was conscious, coherent and co-operative and is well oriented to time, place and person.
He is well nourished and moderately built.
There was no pallor, icterus, cyanosis, clubbing, lymphadenopathy and pedal edema.
Vitals :
At the time of admission :
Temperature : 98.6° F
Pulse Rate : 98 beats per minute
Blood Pressure : 120/60 mm Hg
Respiration rate : 18 breaths per minute
SpO2 : 98% on room air
RBS : 103 mg/dl
Systemic Examination :
Respiratory System : BAE +
Cardiovascular System : S1,S2 heard
Per Abdomen : Tenderness observed on deep palpation around the umbilicus
CNS Findings : Normal
Investigations :
Ultrasound abdomen :
Diagnosis :
Acute on Chronic Pancreatitis
Treatment :
1. Nasogastric Feed
2. Inj. Pantoprazole 40 mg IV OD
3. Inj. Zofer 4 mg IV TID
4. Inj. Tramadol 1 Amp in 100 ml NS IV BD
5. BP Charting - 8th hourly
6. Strict I/O charting
Comments
Post a Comment