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 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 comments on comment box is welcome.

I've 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 a diagnosis and prognosis

A 45year old male who is a resident of nakrekal came to opd with 

CHIEF COMPLAINTS- 

C/o itchy skin lesion on left foot since 10 yrs which initially started as a papule 

C/o pain in the abdomen since 3 days

C/o constipation since 3days

C/o vomitings since 2days

HISTORY OF PRESENT ILLNESS- 

Pt was apparently asymptotic 2days ago then he developed pain in the abdomen-epigastric region. Pain is sudden in onset, gradually progressive. Pain increases more after eating food and on lying in supine position. Pain is relieved on sitting position and on bending forward.

 H/o 3 episodes of vomiting yesterday after eating food. Content- food, non bilious, non projectile, not blood tinged. Constipation since 3days 

No h/o fever , cough , cold, SOB, loose stools, giddiness

HISTORY OF PAST ILLNESS-

Last binge of alcohol consumption 2days ago

H/o similar complaints 2yrs ago diagnosed as acute pancreatitis. 

No H/o diabetes mellitus, hypertension, thyroid disorders,TB,CAD,CVBA, Epilepsy 

TREATMENT HISTORY- 

Application of unknown topical medication on skin lesions .

PERSONAL HISTORY-

Appetite- normal.                                                                 Non-vegetarian 

Bowel- constipation

Micturition- normal

Addictions-

Alcohol- consumes 2 quarters alcohol/day 

Smoking- nil

No h/o drug abuse

FAMILY HISTORY- 

Father is an alcoholic

PHYSICAL EXAMINATION-

GENERAL EXAMINATION- 

No signs of pallor, icterus, cyanosis, clubbing of fingers, lymphadenopathy, oedema, dehydration

VITALS-

Temperature- 97.8

Pulse rate- 76/min

Respiration rate-  18/ min

BP- 110/80 mm Hg

SPO2- 96%

GRBS- 124mg %

SYSTEMIC EXAMINATION-

CVS-

Thrills- No

Cardiac sounds- s1s2 heard

Cardiac murmurs- No

RESPIRATORY SYSTEM-

Dyspnoea- no

Wheeze- no

Position of trachea- central

Breath sounds- vesicular

ABDOMEN-

Shape of abdomen- scaphoid 

Tenderness- no

Palpable mass - no

Hernial orifices - normal

Free fluid- no

Bruit- no

Liver- not palpable

Spleen- not palpable

Bowel sounds- present sluggish 2mins

CNS- pt is conscious coherent and afebrile on touch 

Level of consciousness- conscious 

Speech- normal

Glasgow scale- E4, U5, M6 

Fever chart

INVESTIGATIONS:

HAEMOGRAM

CUE

2D ECHO

UlTRASOUND

ECG


PROVISIONAL DIAGNOSIS-

Acute pancreatitis 

TREATMENT-

NBM till further order

IV fluids 

Inj. TRAMADOL 1 amp in 100 ml NS in IV  

Inj THIAMINE 1 amp in 200 ml NS IV BD 

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