Acute pancreatitis
1701006151,R Jayanth reddy
12th june,2022
General medicine E - LOG Book
Final practical examination short case
R Jayanth reddy
Hall ticket no : 1701006151
Batch-2017
This is an online E-log book to discuss our patient de-identified healthdata shared after taking his/ her guardians sign informed consent
Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aimto solve those patient clinical problem with collective current bestevidence based inputs.
This E-log also reflects my patient centered online learning portfolio. I have been given this case to solve in an attempt to understand thetopic of " Patient clinical data analysis" to develop my competancy inreading and comprehending clinical data including history, clinicalfinding, investigations and come up with a diagnosis and treatmentplan.
Case presentation :
22 Year old Male patient came to the opd with the chief complaints of abdominal pain since 4 days.
History of presenting Illness:
Patient was apparently asymptomatic 4 months back then he developed pain abdomen and vomiting on presenting to a hospital diagnosed as Acute Pancreatitis. He was treated at the hospital and was discharged with the advice to stop drinking alcohol. Then 4 days back , he developed pain over upper abdomen which is of dragging type, radiating to back aggravated on lying down and after eating meals.
The pain increases in sleeping prone position than sleeping than sleeping in supine postion
Patient denies history of fever, nausea, vomiting and diarrhoea.
Patient also gives history of alcohol withdrawal symptoms after the pancreatits episode 4 months back and desries to take up a treatment for deaddiction
Past History:
Not a known case of Diabetes mellitus, Hypertension. Epilepsy,
Cardiovascular diseases. Asthma and tuberculosis
Family History:
No similar complaints in family
Not significant
Personal history:
Takes mixed diet, has early satiety
Sleep is Adequate
Bowel and bladder habits are regular
Addictions: Started drinking alcohol 4 years back with friends started taking alcohol daily since 3 years.
Reduced intake since 3 months. Last intake
was 5 days back of about 250 ml of alcohol.
Smokes 5 beedies per day
General physical examination:
Patient is conscious, cooperative and well oriented to time, place and person.He is thin built.
There is no pallor.
No signs of icterus, cyanosis, clubbing. lymphadenopathy
edema - present
Vitals:
Patient is afebrile
Pulse rate: 92 bpm
Blood pressure: 110/80 mm of Hg
Respirtaory rate: 14 cpm
Systemic Examination:
ABDOMEN EXAMINATION
INSPECTION:
Shape – Flat
Umbilicus –central in position
All quadrants of abdomen are moving equally with respiration.
No dilated veins, hernial orifices, sinuses
No visible pulsations.
A swelling on the left medial coastal border is seen on inspection.
Swelling does not move on respiration.
PALPATION:
Lower margin of the swelling is well defined than upper margin.
No local rise of temperature and tenderness
No guarding, rigidity
Deep palpation- no organomegaly.
PERCUSSION:
There is no fluid thrill , shifting dullness.
Percussion over abdomen- tympanic note heard.
AUSCULTATION:
Bowel sounds are heard.
Investigations:
Serum Lipase: 112 IU/L (13-60)
Serum Amylase: 255IU/L (25-140)
Hemogram:
Hemoglobin: 11.8 mg/dl
Total leucocytes: 14,300 cells/cumm
Lymphocytes: 16(18-20)
Provisional diagnosis: Acute pancreatitis
Treatment:
Nill By Mouth
Intravenous fluids Ringer lactate and normal saline 10ml per hour
Inj. TRAMADOL 100 mg in 100ml normal saline IV BD
INJ. ZOFER 4mg IV BD
INJ. PAN 40 MG IV BD
INJ. OPTINEURIN 1amp in 100 ml nd IV OD
Psychiatric medication:
TAB. LORAZEPAM 2mg BD
TAB. BENZOTHIAMINE 100mg OD
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