CBBLE UDHC SIMILAR CASES

 "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.


Unit 3 & 6

Amc bed 5

Chief complaints:

Patient came to casualty with complaints of pain in abdomen from today morning 


History of presenting illness:

55yr/M barber by occupation was apparently asymptomatic 15 years back then he had c/o pain abdomen diagnosed as intestinal perforation discharged after 1 week and again he complains of abdominal pain since today morning which was in midline between epigastric and umbilicus squeezing type sudden in onset progressive, aggravates on deep inspiration and no radiation not associated with nausea and vomiting.also have c/o chest pain , epigastric region burning type not associated with palpitations and syncopal attacks 

No c/o sob,asthma,pnd 


Past history:

Not a known case of htn/dm/cad/tb/ bronchial asthma 

Surgical history: previously had surgery for intestinal perforation.


Personal history:

Married 

Barber by occupation 

Diet:mixed

Appetite:normal

Bowel bladder movements: regular 

Addictions: alcohol consumption since 25 years 

90-180ml whiskey per day 


Family history: not significant 


O/e:

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

No signs of pallor,icterus,clubbing,cyanosis,lymphadenopathy,pedal edema.

Vitals:

Temp:afebrile

Pr:98bpm

Rr:18cpm

Bp:140/100

Spo2:98%

Grbs:165mg/dl


Systemic examination:

Cvs: S1,S2 heard,no murmurs heard

Rs:BAE +,NVBS heard

P/A: scar present on the epigastric region,soft,tenderness present in epigastric region.  Mild Rigidity present in the epigastric region.

Bowel sounds present 

Cns: NAD

Diagnosis:acute pancreatitis 


Clinical images:






Investigations:

LFT

TB:2.18

DB:0.79

AST:51

ALT:27

ALP:176

TP:7.5

ALB:4.5


RFT

Urea:20

Creatinine:0.9

Na:139

K:3.2

CL:103


S.amylase:579.4


Hemogram:


Cxr:



X ray erect abdomen:



ECG:


Ultrasound abdomen:

Pancreas shows altered echotexture with surface irregularity 

Evidence of peripancreatic fluid collection

Mild ascites

Grade 1 fatty liver 


CT scan abdomen:

Pancreas is edematous with significant peripancreatic and mesentric fat stranding.

Plan:

1.Ivf with ns and rl at 125ml/hr

2.NBM till further order

3.Inj pan 40mg/iv/bd

4.inj zofer 4mg/iv/bd

5.inj tramadol 1amp in 100ml Ns/iv/tid

6.inj optineuron 1amp in 100ml ns/iv/od

7.inj thiamine 1amp in 100ml ns/iv/tid

8.strict input output charting 


Surgery referral:





Ct abdomen images:








This is peripancreatic fat stranding secondary to acute pancreatitis.


Soap notes 

Day 1


S: no fever spikes since yesterday 

Pain subsided 


O:

O/e

Patient is c/c/c

Temp:99.6

Pr:110bpm

Rr:18cpm

Bp:140/100

Spo2:98% at RA

Cvs: S1 S2 +, no murmurs

Rs: BAE +

PA: soft,tender


GRBS: 141mg/dl


A: acute pancreatitis 


P:

1.ivf  with ns and rl at 125ml/hr

2.NBM till further order

3.inj pan 40mg/iv/bd

4.inj zofer 4mg/iv/bd

5.inj tramadol 1amp in 100ml ns/iv/tid

6.inj optineuron 1am in 100ml ns/iv/od 

7.inj thiamine 1amp in 100 mlns/iv/tid

8.strict input output charting



Soap notes 

Day 2

55yr/M


S: no fever spikes since yesterday 

Pain subsided 


O:

O/e

Patient is c/c/c

Temp:afebrile 

Pr:110bpm

Rr:18cpm

Bp:170/100

Spo2:98% at RA

Cvs: S1 S2 +, no murmurs

Rs: BAE +

PA: soft,non tender


GRBS: 122mg/dl


A: acute pancreatitis 


P:

1.ivf  with ns and rl at 125ml/hr

2.NBM till further order

3.inj pan 40mg/iv/bd

4.inj zofer 4mg/iv/bd

5.inj tramadol 1amp in 100ml ns sos

7.inj thiamine 1amp in 100 ml ns/iv/tid

8.strict input output charting




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