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 series of inputs from an available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs 

 

A 29 yr old male patient came to casuality with cheif complaints  of 


 Pain abdomen since 3 days 

Vomitings since 3 days .


 HOPI


Patient is apparently asymptomatic  3 yrs (2018)back then he had pain abdomen and vomiting for which he went to hospital and diagnosed with acute pancreatitis and after 2 yr  (2020 )he got an another episode 

 

Now 3 days back  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 The vomiting was non-bilious and non-projectile


No H/o of fever, body pains , headache ,diarrhea


PAST HISTORY: 


K/c/o pancreatitis  2018,2020 -2 episodes 

Not a k/c/o diabetes ,HTN, TB,asthama,cvd , epilepsy.


PERSONAL HISTORY : 

diet - mixed

Appetite - normal

Bowel ,bladder movements - regular

Sleep - adequate 

Addictions - h/o of smoking stopped 2 yrs back. 

Addictions:  History of alcohol intake since 3 years with a frequency of 3-4 times per week and stopped drinking since 1yr 

Allergies : None



FAMILY  HISTORY: 

No significant  family history 


GENERAL  EXAMINATION 

patient is conscious, Cooperative, coherent 


No pallor 

No cyanosis

No clubbing

No icterus ,

No edema

No Lymphadenopathy 


Vitals 

Bp 130 /70  

HR 86 

PR 22

GRBS 125

spo2 98%

 


SYSTEMIC EXAMINATION 

Cvs:

S1 s2 heard 

no murmurs


Respiratory system

Trachea central in position 

Normal vesicular breathsounds 

Bilateral air entry present 


Per Abdomen : 

Tenderness observed on deep palpation around the umbilicus

No palpable mass, fluid , bruit

No palpable liver  , spleen


CNS :Normal 


PROVISIONAL DIAGNOSIS 

acute on chronic pancreatitis 


INVESTIGATIONS 

CUE , CBP ,serum amylase ,serum lipase,ECG,HIV ,HBsAg,HIV .














TREATMENT:-    

1) INJ ZOFER 4MG

2)INJ PAN 40 MG

3)INJ TRAMADOL 1 AMP IN 100 ML NS

4)REVIEW SOS

5)BP ,PR ,SPO2 monitoring

6)IVF 1Q NS

           1QRL

           1Q DNS



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