26 yr old with pancreatitis

E-LOGS GENERAL MEDICINE


 
Roll no 04 
Hi, i am lasya, 5th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent. This also reflects patients centered care and online learning portfolio. 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. Hope this will be informative!

A 26yr old male patient came to casualty with complaints of pain abdomen since 5 days , associated with vomitings (bilious). Also complained of 
Tenderness in rt .Hypochondriac and epigastrium. 



HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 4 months ago when he developed pain (after taking food) associated with vomitings . He was admitted in a local hospital where he was diagnosed with acute pancreatitis. He got relieved after taking medication.

He then used to consume toddy regularly.
5 days back , he again developed pain Abdomen in rt epigastric and hypochondriac region (not relieved by medication) associated with vomitings ( 3 episodes , bilious , non blood tinged ).



PAST HISTORY: 
Not a k/c/o DM , HTN , CAD , asthma ? , TB .

PERSONAL HISTORY:
Diet - mixed 
Appetite -decreased 
Sleep - normal
Addictions - toddy ( regular )
Bowel and bladder movements - normal 


FAMILY HISTORY:
No significant family history

GENERAL EXAMINATION:
Pallor - not seen
Icterus -not seen
Cyanosis -not seen
Clubbing -not seen
Lymphadenopathy -not seen
Oedema -not seen

VITALS :
Temperature - 99°F
Pulse rate - 78/min
Respiratory rate - 16/min
BP - 110/70 mm Hg 
SpO2 - 98%
GRBS - 144 mg%

SYSTEMIC EXAMINATION:
CVS :
S1 S2 heard 
No thrills and murmurs 

RESPIRATORY SYSTEM:
BAE +
Vesicular breath sounds 

PER ABDOMEN:
Shape of Abdomen - obese
Soft 
Tenderness+

CNS :
NAD 

PROVISIONAL DIAGNOSIS:
acute pancreatitis?

INVESTIGATIONS :
TREATMENT:
1) liquid diet 
2)IVF (NS/RL) @100ml/hr.
3)inj. TRAMADOL 1amp in 100ml NS IV /TID
4)inj. ZOFER 4mg IV/BD
5)Inj.PAN 40mg IV/OD
6)tab .PANCREATO ELAT PO/OD
7) STRICT I/O CHARTING 



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