ACUTE PANCREATITIS
This is an online E Logbook 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 a series of inputs from an available global online community of experts to solve those patients' 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 in the comment box are welcome.
A 50YR OLD MALE
C/O ABDOMINAL PAIN SINCE 5 DAYS
C/O VOMITING 4DAYS BACK
(4-5 EPISODES)
HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC 5 DAYS BACK THEN HE DEVELOPED ABDOMINAL PAIN WHICH IS SUDDEN IN ONSET, GRADUALLY PROGRESSIVE ASSOCIATED WITH VOMITINGS FOR ONE DAY (AROUND 4-5 EPISODES) WHICH ARE SUBSIDED AFTER ONE DAY
PAST HISTORY:
PATIENT HAD SIMILAR COMPLAINTS 3YEARS BACK
K/C/O DM SINCE 5YRS ON TREATMENT WITH GLIMI -M1
N/K/C/O EPILEPSY,ASTHMA,CVA
PERSONAL HISTORY:
DIET- MIXED
SLEEP -ADEQUATE
APPETITE - NORMAL
BOWEL & BLADDER- REGULAR
ADDICTIONS
ALCOHOLIC SINCE 30YRS
1/2 BOTTLE DAILY (AROUND 300ML)
WHISKEY
GENERAL EXAMINATION:
PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE
ORIENTED TO TIME, PLACE, PERSON
ICTERUS PRESENT
NO PALLOR,NO CLUBBING,NO KOILONYCHIA,NO LYMPHADENOPATHY,
NO EDEMA
VITALS:
TEMP-98.4F
BP-140/90MMHG
PR-84BPM
RR-18CPM
SYSTEMIC EXAMINATION:
CVS -S1S2+,NO MURMURS
CNS-NAD
RS-BAE+,NVBS HEARD
PA- SOFT , TENDERNESS+
No GUARDING
No RIGIDITY
INVESTIGATIONS :
HEMOGRAM 2/5/22
APTT
PT
CUE
URINARY ELECTROLYTES
SPOT URINE PROTEIN CREATININE RATIO
SERUM UREA
SERUM ELECTROLYTES
USG
PROVISIONAL DIAGNOSIS:
ACUTE PANCREATITIS WITH ALCOHOLIC HEPATITIS (RESOLVING)
DM SINCE 5YRS
TREATMENT:
1) ENCOURAGE ORAL SIPS OF WATER
2) IVF DNS@100 ML /HR
3)INJ .CEFTRIAXONE 1GM /IV/BD
4)INJ.TREMADOL 1AMP IN 100 ML NS IV SOS
5) STRICT I/O CHARTING
6) MONITOR VITALS 4TH HOURLY
Comments
Post a Comment