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acute pancreatitis

38YR OLD MALE WITH ACUTE NECROTISING PANCREATITIS

Oct 18th, 2021
 
Medicine E-Log

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 a series of inputs from an 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 inputs in the comment box is welcome

Name : I.AASRITHA

Roll no. : 49

Batch : 20I9

CASE :

 38yr old male patient resident of Suryapet, farmer by occupation came to our Gen Med OPD on 15th Oct'2021 with cheif complaints of:

       Abdominal pain since 4days

       Vomitings since 4days

History of presenting illness:

  Patient was apparently asymptomatic 4 days back then developed pain in abdomen which was in epigastric region, squeezing type of pain,non radiating, aggravated on eating food and relieved on lying down.

  Abdominal pain is associated with vomitings, non bilious, non projectile, food as content.

History of consumption of alcohol 4days back

History of constipation since 4days back

Decreased urine output and burning mictirution was mentioned

 No history of fever,chills, headache

Past history:

No similar complaints in the past. 

 Patient is not a known case of diabetes mellitus, hypertension,  Tb, Asthma, Cad. 

Personal history:

 DIET : mixed

APPETITE : Decreased appetite

SLEEP : disturbed due to pain

BOWEL AND BLADDER :  Constipation, Decreased urine output, burning micturition

ADDICTIONS : 

Alcohol : consumes around 90ml -daily since 20years

ALLERGIES : No food and drug allergies. 

 Family history:

   Patient's mother is diabetic since 15years

 General examination:

Patient is conscious coherent and cooperative. 

VITALS : 

Temp : Afebrile

BP : 110/80mmHg

PR : 90bpm

RR : 20 cycles/min

SpO2 : 98%

NO SIGNS OF Pallor, Icterus, Cyanosis, Clubbing, 

Clubbing, Lymphadenopathy and Edema. 

 Systemic Examination:

 CVS: S1 and S2 heard. No murmurs

RESPIRATORY : Normal vesicular breath sounds heard+ No crepts heard

P/A : Distended abdomen,tenderness around epigastric region and no evidence of  organomegaly. Bowel sounds are sluggish

   



CNS : No neurological deficits.

 Lab Investigation:

  CBP :  

  • HB: 18.1gm/dl
  • TLC: 15,300 cell/cumm
  • NEUTROPHIL : 87%
  • LYMPHOCYTE : 05%
  • EOSINOPHIL : 01%
  • MONOCYTES : 07%
  • BASOPHIL : 00%
   LFT :

  • Total bilirubin : 2.24gm/dl
  • Direct bilirubin : 0.93mg/dl
  • AST : 57 IU/L
  • ALT : 113 IU/L
  • ALP : 220 IU/L
  • Total proteins :72gm/dl
  • Albumin : 4.2gm/dl
  • A/G : 1.40
   Serum Creatinine :

  • Creatinine : 0.8mg/dl
   Serum Electrolytes :

  • Sodium : 136mEq/l
  • Potassium : 3.4mEq/l
  • Chloride : 98mEq/l
    Serum Amylase :     

  • Amylase : 446IU/L
    Serum Lipase :

  • Lipase : 121IU/L
    CECT -ABDOMEN (17/10/2021)
      

    ULTRASOUND (17/10/2021)
   

  

  PROVISIONAL DIAGNOSIS :

    Acute Necrotising Pancreatitis secondary to alcohol.

   Treatment :

  1. IVF : Ringerlactate, Normal saline 150ml/hr
  2. Inj Pantop 40mg/IV/OD
  3. Inj Zofer 4mg/IV/OD
  4. Inj Tramadol 100ml/NS/IV/SOS
  5. Syp Lactulose 10ml/PO/BD
  6. Monitor Vitals 4th hourly
  7. Soap coater enema if stool not passed.

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