Case of acute pancreatitis

 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 patients clinical problems with collective current based inputs.

Chief complaints 

Patient came to the casuality with complaints of 
  pain abdomen since 7hrs
Diffuse pain all over abdomen 
Sudden in onset,non progressive 
Patient was aymptomatic 7hrs ago when he had pain abdomen which was diffuse ,sudden in onset,non progressive,dull achivy type
ass/c 1 episode of lose srools on the same day 
No c/o vomitings,fever,SOB

History of presenting illness

Last alochol intake:2dyas ago-90ml
Occasional drinker 
Pt  had alcohol intake daily 
No other addictions

History of past illness

Had similar complaints in the past in 2019
N/K/C/O DM,HTN,TB,thyroid disorders,epilepsy

Personal History

Married 
Photographer by occupation 
Diet: mixed 
Appetite:Normal 
Bowel bladder moments: regular
Addictions : Alcohol consumption 90ml per day

Family history

Not significant

On examination

Pt is conscious,coherent and cooperative well oriented to time,place,person 

No signs of pallor,icterus,clubbing,cyanosis,lymphadenopathy,pedal oedema 

Vitals

Temp:98.4*F
PR:67
Rr:21/ min
Bp:140/100
Spo2:99%
GRBS:129mg%

Systemic examination

CVS: S1,S2 heard, no murmurs heard 
Resp:NVBS heard 
Abdomen: 
Scaphoid in shape abdomen
Tenderness present,no palpable mass 
Bowel sounds present 
CNS :NAD 

Investigations:

LFT 
TB: 2.04mg/dl
DB:1.09mg/dl
AST:37IU/L
ALT:24IU/L
ALP:173IU/L

Blood urea :37mg/dl

RBS:127mg/dl

Uric acid:6.1mg%

Hemogram 


ECG 






Ultrasound report :

Pancreas showing altered echotexture of body
No ascitis 
No lymph adenopathy 
Bladder minimally distended 
Pelvis couldn't be assessed 

PROVISIONAL DIAGNOSIS:
ACUTE PANCREATITIS

TREATMENT PLAN :
1.IVF with NS,RL,DNS@ 150ml/hr 
2.NBM till further order
3.INJ  PANTOP 40mg IV/BD
4.INJ ZOFER 4mg IV/TID
5.INJ TRAMADOL 1AMP in 100ml NS IV/TID
6.INJ BUSCOPAN 2CC IV
7.I/O- CHARTUNG 
8.TEMP-CHARTING 
9.GRBS- 6th hrly





















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