59 K. Rithika Vasantha

Greetings to one and all who are currently reading my blog. This is Rithika, a third semester medical student. 
                     
                       This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 patient's clinical problems with collective current best evidence based inputs. 


Note : This blog had been done under the guidance of Dr. Jancy ( Intern). 

A 35 YR OLD MALE WITH ACUTE ON CHRONIC PANCREATITIS

Chief complaints:

• Pain abdomen since 20 days ( lt. hypochondriac, relieved in sitting position) 

• Chest pain ( lt. side) since 20 days

• H/O vomiting last  ,  1 episode

• No h/o fever, loose stools

• No h/o palpitations, SOB etc. 

History of present illness:

• Patient was apparently asymptomatic 20 days back ,  but then developed pain  abdomen in left hypochondriac region which relieved on sitting position along with left sided chest pain. 

• He has history of vomiting - 1 episode last night

History of past illness:

• He is a k/c/o DM and is on OHA's. 

• Had pancreatitis 2 yrs back

Treatment history:

•  Is under treatment for DM

• Has no treatment history of HTN, CAD, stroke, asthma, TB, antibiotics, hormones, chemotherapy ,  blood transfusions and surgeries

Personal history:

• Pt. is married

• Has normal appetite and follows a mixed diet

• His bowels are regular and micturition is normal. 

• Has no known allergies

• He is alcoholic since 20 yrs and consumes 15 units of alcohol per day. 

Family history:

• Has no family history of DM, HTN, CAD, TB, asthma, chemoradiation, heart diseases, strokes, hormones, antibiotics, surgeries. 

Physical Examination:

• Has no pallor, icterus, cyanosis, clubbing of fingers and toes, lymphadenopathy, dehydration , oedema of feet and malnutrition. 

Vitals :

• Temperature - afebrile
• PR - 98/min
• BP - 120/90 mmHg
• RR - 22/min
• SPO2- 99%
• GRBS - 277mg%

Systemic Examination

A. Cardiovascular system

• S1 and S2 heard


B. Respiratory system

• No dyspnoea and wheeze
• Trachea is central in position
• Breath sounds - vesicular
• BAE +


C. Abdomen

• Shape of abdomen - scaphoid
• soft and tender in lt. hypochondriac region
• Palpable mass present
• Hernial orifices are normal
• No bruits, free fluid present
• liver, spleen are not palpable

Ultrasound:

•  Altered echotexture of body of 
• GB sludge


D. Central Nervous system

• Pt. is conscious, coherent and cooperative. 
• Speech is normal
• No signs of meningeal irritation

Provisional Diagnosis

   ACUTE ON CHRONIC PANCREATITIS WITH K/C/O DM ( pancreatic - exocrine insufficiency) 

Investigations:

On 14.9.21

• Amylase - 45 IU/L
• Lipase - 23 IU/L
• ALP - 184 IU/L









On 16.9.21



Treatment:

• IV - NS @ 100ml/hr
• IV - RL @ 100ml/hr
• Inj. PAN 40 mg IV/BD
• Inj. OPTINEURON 1 amp in 100ml NS/IV/OD
• Inj. ZOFER 4mg IV/BD
• Strict I/O charting
• Ryles tube insertion with urobag
• Inj. Thiamine 2 ampules
• Inj. HAI S/C acc. To GRBS
• NBM till further orders
• BP, PR, SPO2, monitoring 4th hourly
• GRBS monitoring 6th hourly
• Inj. TRAMADOL 1 amp in 100ml in NS /IV/SOS

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