Case 1

 

CASE OF 32 /M WITH ACUTE PANCREATITIS SECONDARY TO ALCOHOLISM UNDER EVALUATION

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 diagnosis and treatment plan.

15 /9/2021

32 Year Old patient lorry driver by occupation came to casualty with cheif complaints of  "PAIN ABDOMEN " since one day.

Patient was apparently asymptomatic 1 day ago.

# Patient had alcohol intake  today morning (14/09/21), and had food in the afternoon.

Then he developed pain in abdomen at epigastric region, throbbing type, non radiating.

#Aggravayed on Taking food .

Not associated with nausea, vomiting , constipation and loose stools, 

NoHistory of fever and burning micturition.

PAST HISTORY

# Not a known case of hypertension ,diabetes epilepsy, tuberculosis ,asthma.

No similar complaints in past.

PERSONAL HISTORY

Diet - mixed

Appetite -normal

Sleep-normal

Bowel and bladder movements- regular

#Habits- alcohol intake of 90-180ml per day since 12 yrs

Tobacco chewing since 12 yrs and 

Smoking:cigarrete 3-4 per day since 10yrs

ON EXAMINATION 

Patient was consious ,coherent ,cooperative well oriented to time place and person.

Patient was well built and was sitting in posture

GENERAL PHYSICAL EXAMINATION

Pallor - absent

Icterus -absent

Cyanosis -absent

Cludding -absent

Generalised lymphadenopathy -absent

VITALS

 Temperature -AFEBRILE, 

Pulse rate 88 BPM, 

Respiratory rate 16 CPM , 

BP 130/80 mm Hg

 spo2 98% at Room air.

SYSTEMIC EXAMINATION

CVS : Inspection:

Chest wall is bilaterally symmetrical. 
No precordial bulge .
Palpation: 
JVP - normal

Apex beat - felt in the left 5th intercostal space in the mid clavicular line. 
Auscultation: 
S1, S2 heard , No murmurs.

RESPIRATORY SYSTEM: 

Position of trachea:  central 
Bilateral air entry , normal vesicular breath sounds
 heard.
 
No added sounds. 

CNS: 

Patient is Conscious 

Speech: normal 

No signs of Meningeal irritation 

Motor & sensory system: normal 
Reflexes: present 
Cranial nerves: intact 

PER ABDOMEN: 

On Inspection :

Abdominal  distention - absent

All quadrants moving equally with respiration 

Umbilicus - central and inverted

No scars, dilated veins, prominent venous pulsations

 ,visible pulsations

On  Palpation :

Superfical palpation- no local rise of temperature and no tenderness

Deep palpation- 

No guarding , rigidity 

Tenderness in left  hypochondrium and epigastrium

On Percussion  :   

Tympanic note heard 

No shifting dullness

On  Auscultation   : Bowel sound heard

PROVISIONAL DIAGNOSIS:Acute pancreatitis? Secondary to alcohol dependence

INVESTIGATIONS

amylase - 42IU/L

Lipase - 24IU/L

Ultrasound -   # altered echotexture of body of pancreases

Hemogram - 

Hb-14.3

TLC-11400

RBC-4.35 L

PCF-2.05

PCV-40.1

LFT.

TB- 2.21

DB- 0.92

AST-  147

ALT-  145

ALP- 145

RFT:.

Urea-  18

Creatine -   1.0

Na+ -  141

K+ -  3.5

Cl- 98

FLP :

Total cholestrol- 162

TGL-  78

HDL- 41

LDL- 94

VLDL-156

Treatment:

Day1

Soft oral diet

IVF - NS, RL, DNS

injection pan 40 mg

Inj  optineuron 1amp in 100ml NS

Inj Thiamine 1 amp in 100ml/NS/IV/BD

Inj Tramadol 1 amp in 100ml/NS/IV/SOS

Day 2

Soft oral diet

IVF - NS, RL, DNS

injection pan 40 mg

Inj optineuron 1amp in 100ml NS

Inj Thiamine 1 amp in 100ml/NS/IV/BD

Inj Tramadol 1 amp in 100ml/NS/IV/SOS

Day3

Soft oral diet

IVF - NS, RL, DNS

injection pan 40 mg

Inj  optineuron 1amp in 100ml NS

Inj Thiamine 1 amp in 100ml/NS/IV/BD

Inj Tramadol 1 amp in 100ml/NS/IV/SOS


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