26 year male with pain abdomen and vomitings

 

26 year old male with Recurrent Acute Pancreatitis 

- September 12, 2022
 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 patients clinical problems with collective current based inputs.

Patient is a 26 year male, car driver by occupation came to the casualty at 1am with complaints of : 

  pain abdomen since 1 day
4-5 episodes of vomitings

History of presenting illness

Patient was aymptomatic 6 months back. Then he developed pain abdomen not associated with vomitings not admitted to PE hospital. Subsided on taking medication (augmentin, Tramadol) 

Now today at 1am the patient developed pain abdomen sudden in onset and associated with 2 episodes of vomitings which were bilious. 

Had similar complaints in the past around 12 years back. 

History of past illness

N/K/C/O DM,HTN,TB,thyroid disorders,epilepsy

Personal History

Married 

Car driver by occupation 

Diet: mixed 

Appetite: lost

Bowel bladder moments: regular

Addictions : Chronic alcoholic, stopped 1 month back. 

Family history

Not significant

On examination
Pt is conscious,coherent and cooperative well oriented to time,place,person 
No signs of pallor,icterus,clubbing,cyanosis,lymphadenopathy,pedal oedema 


Vitals
Temp:98.6°F
PR: 82
Rr: 16/ min
Bp:120/70 mm Hg. 
Spo2: 98%
GRBS:102mg%

Systemic examination
CVS: S1,S2 heard, no murmurs heard 
Resp: BAE +
CNS :NAD 
Abdomen: 
Soft, mild tenderness in epigastrium & left hypochondrium no guarding, non ? Bs + 


Investigations:

HCV, HIV , HbsAg : negative
Blood Urea : 14mg/dl
Sr. Creatinine: 0.8 mg/dl
CRP : 2.4 mg/dl 

FBS: 86 mg/dl

Blood group : A+ 

Hemogram 


Sr. Electrolytes 


Provisional diagnosis: Acute Pancreatitis

Treatment History 

Day 1 

NBM TIL FURTHER ORDERS

• INJ TRAMADOL IN 100ML NS TID 

• INJ PAN 40 mg OP IV

•INJ ZOFER 4mg IV 

• INJ CIPROFLOXACIN 500mg IV BD 

• IV fluids NS /RL / DMS (@75 ml/min)

 GRBS -every 6th hourly 

BP every 4th hourly 

Day 2 

• INJ TRAMADOL 1amp IN 100ML NS TID 

• INJ PAN 40 mg OP IV

•INJ ZOFER 4mg IV 

• INJ CIPROFLOXACIN 500mg IV BD 

• IV fluids NS /RL / DMS (@75 ml/min)

 GRBS -every 6th hourly 

BP every 4th hourly 

Day 3 

• INJ TRAMADOL IN 100ML NS TID 

• INJ PAN 40 mg OP IV

•INJ ZOFER 4mg IV 

• INJ CIPROFLOXACIN 500mg IV BD 

• IV fluids NS /RL / DMS (@75 ml/min)

 GRBS -every 6th hourly 

BP every 4th hourly 

Patient discharged on day 4 . 

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