37 year 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 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-centred online learning portfolio and your valuable inputs on the 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 treatment plan.

A 37 yr old male , photographer by profession came with the complaints of pain abdomen since 6 p.m. the previous day.

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic till the previous day when he developed pain abdomen which was diffuse all over the abdomen, sudden in onset, No progressive, dull aching type associated with 1 episode of loose stools on the same day.

No c/o vomitings , fever, SOB.

The patient is an occasional drinker since the last 15 years but since he is a photographer and this is the supposed season of vivid events and marriages, the patient was said to enjoy himself in the festivities and has consumed increased amounts of alcohol in the past few days.

Last alcohol intake 90 ml whisky.

The patient consumed approximately 250 ml 3- 4 times before the last intake 2-3 days between every binge.

No other known addictions.

N/k/C/o DM, HTN, Thyroid disorders, TB, BA, Epilepsy.

GENERAL EXAMINATION

Patient was conscious , coperative , coherent 

pallor , icterus, cyanosis, clubbing, lymphadenopathy,edema are absent 

vitals :- 

temp.  98.4 F 

BP 140/100 mm hg 

PR 67 bpm.

RR 21 cpm

spo2 99 @RA 

GRBS  129 

SYSTEMIC EXAMINATION :- 

CVS :- S1 , S2 heard 

RS. :- bae present 

P/A : rigid , tender (diffuse), guarding present, bowel sounds heard, minimal fluid present

CNS :- sensory system intact 

                 motor system.  intact 

                 reflexes normal 

INVESTIGATIONS 

Surgery referral was done

PROVISONAL DIAGNOSIS :- ACUTE PANCREATITIS 

TREATMENT :- 

1.IVF NS, RL, DNS AT 150 ml/hr

2. NBM TILL FURTHER INSTRUCTIONS

3. Inj pantop 40 mg iv /bd 

4. Inj zofer 4 mg iv /sos

5. Inj TRAMADOL 1amp in 100 ml NS iv/tid

6. Inj BUSCOPAN 2cc iv/sos

7. I/O charting

8. Temp charting

9. GRBS charting