ACUTE PANCREATITIS

ACUTE PANCREATITIS

This is an online E Logbook 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 a series of inputs from an available global online community of experts to solve those patients' 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 in the comment box are welcome.

A 50YR OLD MALE
C/O ABDOMINAL PAIN SINCE 5 DAYS
C/O VOMITING 4DAYS BACK 
(4-5 EPISODES)

HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC 5 DAYS BACK THEN HE DEVELOPED ABDOMINAL PAIN WHICH IS SUDDEN IN ONSET, GRADUALLY PROGRESSIVE ASSOCIATED WITH VOMITINGS FOR ONE DAY (AROUND 4-5 EPISODES) WHICH ARE SUBSIDED AFTER ONE DAY


PAST HISTORY:
PATIENT HAD SIMILAR COMPLAINTS 3YEARS BACK

K/C/O DM SINCE 5YRS ON TREATMENT WITH  GLIMI -M1

N/K/C/O EPILEPSY,ASTHMA,CVA

PERSONAL HISTORY:

DIET- MIXED
SLEEP -ADEQUATE
APPETITE - NORMAL
BOWEL & BLADDER- REGULAR
ADDICTIONS
ALCOHOLIC SINCE 30YRS
1/2 BOTTLE DAILY (AROUND 300ML)
WHISKEY

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE
ORIENTED TO TIME, PLACE, PERSON

ICTERUS PRESENT

NO PALLOR,NO CLUBBING,NO KOILONYCHIA,NO LYMPHADENOPATHY,
NO EDEMA

VITALS:
TEMP-98.4F
BP-140/90MMHG
PR-84BPM
RR-18CPM

SYSTEMIC EXAMINATION:

CVS -S1S2+,NO MURMURS
CNS-NAD
RS-BAE+,NVBS HEARD

PA- SOFT , TENDERNESS+
No GUARDING
No RIGIDITY


INVESTIGATIONS :
HEMOGRAM 2/5/22

BGT
APTT
PT
CUE
URINARY ELECTROLYTES

SPOT URINE PROTEIN CREATININE RATIO

RBS
LFT 2/5/22
LFT 4/5/22
LFT 5/5/22
LFT 6/5/22

SERUM UREA
SERUM CREATININE
SERUM URIC ACID
SERUM  ELECTROLYTES
SERUM AMYLASE
SERUM LIPASE
USG
ECG
CHEST X RAY

DVL REFERRAL



PROVISIONAL DIAGNOSIS:
ACUTE PANCREATITIS WITH ALCOHOLIC HEPATITIS (RESOLVING)
DM SINCE 5YRS

TREATMENT:
1) ENCOURAGE ORAL SIPS OF WATER
2) IVF DNS@100 ML /HR
3)INJ .CEFTRIAXONE 1GM /IV/BD
4)INJ.TREMADOL 1AMP IN 100 ML NS IV SOS
5) STRICT I/O CHARTING
6) MONITOR VITALS 4TH HOURLY. 

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