37 yr Male Auto Driver By Occupation Came With Cheif Complaints Of Pain Abdomen
CBBLE UDHC SIMILAR CASES.
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37 yr Old Male Auto Driver By Occupation Came to Casualty with C/o Pain In the Epigastric Region since 1 AM ( 16/03/22 )
HOPI :-
Patient Was Apparently Asymptomatic Till yesterday Night Then He Noticed Pain In The Epigastric Region At 1 AM after Passing Stools After Waking Up From The Bed ( After Decreased Alcohol Sedation Consumed Last Night , 180 Ml Whisky ). Then The Pain Was Gradually Increased to Severity in The Morning 6 AM , Squeezing Type Radiating To the Back , Associated With Vomitings ( 3 Episodes in A Day ) food Particles As Content , Non Bilious , Non Projectile .
Pain Aggravated While Sitting , and Decreased on Sleeping in Right Lateral Position
Patient Also Noticed Pain in the Left hypochondrium and Thought To be Heart Problem and Approached Nearest Cardiologist In Nalgonda . Cardiologist Said , There is No Problem Related to the Heart and Advised Admission In Some Other Hospital For The Pain The Patient Was Complaining .
The Patient Came To our hospital for Further evaluation and Treatment .
PAST HISTORY :-
Known case of Hypertension Since 3 months ( Diagnosed In the Government Hospital And Advised To Take Medication , Pateient used Medication for A Week and Then Stopped .)
No Similar complaints In the past .
No H/o DM, TB , Epilepsy , Asthma.
TREATMENT HISTORY :
4years Back the Patient Said to taken Treatment For Urinary tract infection in our hospital and Symptoms Were Releived.
ADDICTIONS :-
1) Alcohol - Consuming Whiskey Daily Evening Quantity 180 ML , Since 15 years.
2) Cigarette - Smokes 4-5 Ciggerates / Day Since 10 years.
3) Gutka - consumes 10-15 Packs / day Since 10 years.
GENERAL EXAMINATION :-
NO Pallor , Icterus , Cyanosis , Clubbing ,lymphadenopathy.
Vitals
Temp - afebrile
BP - 160/100 mm hg
PR - 89 bpm.
RR - 19 cpm
spo2 100 @RA
GRBS - 158 mg/dl @ 8 am
CVS - S1, S2 heard
RS. :- bae present
P/A: soft , tender , Guarding Present
CNS :- NAD
INVESTIGATIONS
Serum Lipase - 94
Serum Amylase - 268
HAEMOGRAM
Haemoglobin - 19.7
Total Count - 10,700
RBC -
Platelet Count - 2.35
RFT
S Urea - 12
S Creatinine - 0.9
S Calcium - 9.9
Na - 140
K - 3.7
Cl - 98
LFT
Total Bilirubin -
Direct Bilirubin - 0.98
Ast - 45
Alt - 34
Alk P - 165
Total Protein - 8.1
Albumin - 4.1
A/G - 1.03
CRP - Positive 2.4 mg/dl
HbA1c - 7.0 %
Serology - Negative
ECG
USG abdomen
CECT Report
PROVISONAL DIAGNOSIS
Acute Pancreatitis
Treatment
1. Nbm till further orders.
2. IVF- NS & RL @ 100ml/hr.
3. Inj. Pantop 40mg/IV/OD.
4. Inj. Zofer 4mg/IV/SOS.
5. Inj. Tramadol 1amp in 100 ml/NS/IV/BD.
6. Inj. THIAMINE 2amp in 1 NS/IV/TID.
7. Monitor vitals.
8. Measure abdominal girth.
SOAP NOTES
AMC Day 2 Bed 6
S :
C/o Pain Abdomen Decreased
O - Patient is conscious,coherent,cooperative
vitals :
Temp - afebrile
BP - 180/100 mm hg
PR - 98 bpm.
RR - 20 cpm
spo2 - 100 @RA
GRBS - 154 mg/dl @ am
CVS - S1, S2 heard
RS - bae present , Decreased Breath Sounds In IAA
P/A - Soft , tenderness Present In Umbilical Area
bowel Sounds - Sluggish
Stools - Not Passed
CNS - NAD
A - Acute Pancreatitis
P -
1. Nbm till further orders.
2. IVF- NS & RL @ 150ml/hr.
3. Inj. Pantop 40mg/IV/OD.
4. Inj. Zofer 4mg/IV/SOS.
5. Inj. Tramadol 1amp in 100 ml/NS/IV/BD.
6. Inj. THIAMINE 2amp in 1 NS/IV/TID.
7. Monitor vitals.
8. Measure abdominal girth.
AMC Day 4 Bed 6
S :
C/o Pain Abdomen Decreased
O - Patient is conscious,coherent,cooperative
vitals :
Temp - afebrile
BP - 140/90 mm hg
PR - 82 bpm.
spo2 - 98 @RA
GRBS - 96 mg/dl @ am
CVS - S1, S2 heard
RS - bae present , Decreased Breath Sounds In IAA
P/A - Soft , no tenderness In Umbilical Area
bowel Sounds - Sluggish
Stools - Not Passed
CNS - NAD
A - Acute Pancreatitis with denovo Type 2 Diabetes & Hypertension
P -
1. IVF- NS & RL @ 75ml/hr.
2. Inj. Pantop 40mg/IV/OD.
3. Inj. Zofer 4mg/IV/SOS.
4. Inj. Tramadol 1amp in 100 ml/NS/IV/BD.
5. Inj. THIAMINE 2amp in 1 NS/IV/TID.
6. Monitor vitals.
7. Measure abdominal girth.
AMC Day 5 Bed 6
S :
No Fresh Complaints
O - Patient is conscious,coherent,cooperative
vitals :
Temp - afebrile
BP - 180/110 mm hg
PR - 94 bpm.
RR - 18 cpm
spo2 - 100 @RA
GRBS - 134 mg/dl @ am
CVS - S1, S2 heard
RS - bae present
P/A - Soft , No tenderness
bowel Sounds - Sluggish
Stools - Passed
CNS - NAD
I/O - 1500/1300 ml
A - Acute Pancreatitis with denovo Type 2 Diabetes & Hypertension
P -
IVF- NS & RL @ 75 ml/hr.
Inj Pantop 40mg/IV/OD.
Inj. Zofer 4mg/IV/SOS.
Inj. Tramadol 1amp in 100 ml/NS/IV/ SOS
Inj. THIAMINE 2amp in 1 NS/IV/TID.
Tab Telma 40 mg
Monitor vitals.
