45 y/o Male with Acute on chronic Pancreatitis , chronic alcoholism

 


 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 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 on the comment box.


CONSENT AND DEIDENTIFICATION : The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever.





Pt came with c/o abdominal pain since 2 days

C/o vomiting since 2 days 6 episodes/day


HOPI

Patient was apparently asymptomatic 2 days back , then developed pain abdomen above the umbilicus, non-radiating , squeezing type, associated with nausea. Pt c/o vomiting, non-projectile,bilious,green color, liquid.

No h/o fever, diarrhoea

H/o melena since two days

No h/o blood in urine or urinary color change

No h/o blunt trauma to abdomen

History of past illness

K/c/o DM since 5-6 years

N/k/c/o htn, cad, cva, epilepsy,thyroid disorders


On medication: 12 u mixtard at night, metformin, sitagliptin 50 mg.


Personal History:

Occupation: lorry driver

Appetite - reduced due to alcoholism

Mixed diet

Bowels and Bladder regular

Alcoholic- since 20-25 years ago, drinks daily- 360-750 ml, sleep and appetite disturbances for 3-4 days of stopping alcohol.

Betel nut chewer- 1 packet for 2 days , same qty for 25 years


Family History:

No significant family history


Physical Examination:


General Examination: 

Patient is c/c/c

No Pallor, icterus, cyanosis, koilonychia, Lymphadenopathy, edema

Temp: 98 F

Pulse rate: 84/ min

RR: 22 /min

BP: 110/70

SpO2: 98% at RA

GRBS: 254

Reflexes normal


Systemic Examination:

GIT:

Abdomen scaphoid in shape

No tenderness, no palpable mass, normal hernial orifices

No free fluid,

No organomegaly


CVS:

S1 S2 heard, no audible murmurs


CNS: No FND

Pt is c/c/c , speech is normal

CN intact, No motor or sensory deficits


GCS: E4 V5 M6



Investigations:

USG abdomen: Grade I fatty liver

Internal echoes noted in urinary bladder, likely cystitis, b/l raised echogenicity of the kidneys, correlate with rft, gall bladder sludge.



Investigations:












Diagnosis:


Acute on Chronic Pancreatitis



Treatment: 

1. Inj. Tramadol in 100 ml NS stat

2.Inj. Ondansetron 8 mg stat

3.Inj. Thiamine 400 mg in 100 ml NS stat




Comments

Post a Comment

Popular posts from this blog

My Journey as an Intern In Medicine

Image
I am Sanjana Thota, Intern posted in the General Medicine Department from 1/12/23 until 31/1/24. “To cure sometimes, to relieve often, to comfort always.”- Edward Livingston Trudeau.  1) Self Reflection on my Medical Career: My first case taken in the manner if an e-log during my 2nd year Medicine Posting. https://sanjanathotarollno141.blogspot.com/2022/09/a-70-yr-old-female-with-involuntary.html?m=1 Through this process, I learned how to document the process of history taking, diagnosis, investigations and the treatment of a patient. During my internship, I came across cases such as DKA, Heart Failure, CKD, SLE, Septic Shock,CVA, Epilepsy and common chronic diseases such as Diabetes, Hypothyroidism and Hypertension. I witnessed an episode of GTCS and the acute management of such a case in the ICU. I also learned how to diagnose and further evaluate a case of MI / ACS.I learned about spinal cord lesions, how to perform a full CNS examination and how to localize a stroke. My journey in
Read more

60 y/o male with hypertension, heart failure and decreased urine output.

Image
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings investigations and come up with diagnosis and treatment plan. Patient was apparently asymptomatic 3 months ago, then he developed b/l pedal edema, initially extending only up to the ankles, which gradually progressed up to both the thighs, over the last 15 days. Patient c
Read more

A 70 yr old female with involuntary movements in upper and lower limb

Image
MEDICINE E LOG BOOK This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. CHIEF COMPLAINT Altered sensorium since 12:00 am midnight, involuntary movement in upper and lower limb since 12:00 am, loss of speech after 12:00 am HISTORY OF PRESENTING ILLNESS Pt was app
Read more