35 yr old male with 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 inputs on the comment box is welcome.

Team- Interns 

M Supriya

Mohitha

K Sowmya

Sanjay

Amrutha

Dr.Druga Krishna PGY1

Dr.Ajith Kumar PGY2

Dr.Laxma Reddy PGY3

Dr.Manasa PGY3

Dr.Vijaya Lakshmi (Ast.Prof.)



35yr old male Auto Driver from Valigonda came to OPD with 
C/o pain abdomen from 3 days and nausea from 3 days

The patient was apparently asymptomatic 3 days back then he had pain in the epigastrium which was sudden in onset,progressive, radiating to back, no aggravating and relieving factors.

5 days prior to development of pain abdomen he consumed alcohol for 3 days( whiskey/180ml/day) 

H/o vomitings from 2 days, 2 episodes/day, non bilious, contents were food particles.

H/O loss of appetite from 3 days.

No h/o fever, loose stools,tachycardia,palpitations,decreased urine output.


H/o similar complaints 1 yr back when he had pain abdomen and vomitings after consumption of alcohol and was admitted to a private hospital for 3 days. 

Not a k/c/o HTN,DM,TB,Epilepsy,thyroid disorders,Bronchial Asthma.


Personal history- 

Drinks occasionally(whiskey 180ml) from 17 yrs.

Mixed diet, 

sleep decreased due to pain abdomen, 

normal bowel and bladder movements. 


O/E:

Patient conscious,coherent,cooperative.

Vitals: 

Afebrile

BP- 120/80mmhg sitting position right arm

PR- 80bpm regular rhythm 

RR-16cpm

Systemic examination:

CVS-S1S2 +

RS- BAE + 

P/A- Inspection:

Shape of abdomen-distended.

Umbilicus central,inverted

No engorged veins, scars, sinuses.

No visible pulsations.

Palpation:

No local rise of temperature.

Diffuse tenderness present in all quadrants.

No palpable swellings. 

Percussion: Tympanic

Auscultation:

Bowel sounds heard.


Psychiatry opinion:







Gastroenterologist opinion:




Investigations:


Serum lipase- 164

Serum amylase- 249






Ranson’s Score-0
BISAP-0

Serology negative.

 

Diagnosis- ?Acute Pancreatitis.


Treatment- 

1.NBM.

2.IVF- RL,DNS @100ml/hr

3.Ryles tube inserted.

4.Inj.Pan 40mg IV/OD

5.inj. Tramadol 1 amp in 100ml NS IV/OD.

6.inj. Optineuron 1 amp in 100ml NS IV/OD

7.Inj. Zofer 4mg IV/OD 

8.Bp,Pr,Spo2 monitoring 4th hrly

9.GRBS monitoring



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