52 Male Acute interstitial 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

CHEIF COMPLAINTS:

52 year old male shepherd by occupation came to OPD with cheif complaints of

-Pain abdomen since 3 days 

-1 episode of vomitings ( 2 days back ) 

HOPI:

Pateint was apparently asymptomatic 3 days ago then he developed pain in the abdomen which is of squeezing type ,diffuse all over the abdomen,non radiating,not associated with loose stools,fever, burning micturition, distention of abdomen

H/o 1 episode of vomiting 2 days ago which is non bilious,non projectile,food particals as content.

PAST HISTORY:

K/c/o pancreatitis since 2 years

H/o similar complaints once in every 6 months since then .

Not a k/c/o HTN,DM,CVA,TB,ASTHMA 

PERSONAL HISTORY:

-Patient is  alcoholic since 40 years (regular ) once in 2-3 days . 

Occasional alcoholic since 2 years once in 2 months ,last binge was 2 months ago.

GENERAL EXAMINATION:

Patient is conscious coherent and cooperative 

No pallor ,icterus , clubbing,cyanosis,lymphadenopathy ,pedal edema

BP- 110/70mmhg

PR -90bpm

RR-18cpm

Spo2 99% at room air 

GRBS - 91mg/dl

Temperature -98.6F


SYSTEMIC EXAMINATION:

CVS: s1,s2 heard ,no Murmurs,jvp not raised 

RS: BAE,no added sounds ,NVBS, 

P/A: soft, non tender,bowel sounds can be heard 

CNS:

Pt is conscious

Speech is normal

No meningeal signs

Normal cranial nerve examination, motor system, sensory system

GCS: E4,V5,M6


 Reflexes:


       R       L


B  ++      ++


T   ++       ++


S  ++       ++


K ++     ++


A   ++    ++


P  Flexor   Flexor  

Clinical Images and Investigations:












28/04/2023:













29/04/2023:





30/04/2023:







01/05/2023:




02/05/2023:




Provisional Diagnosis:

Acute interstitial pancreatitis.

Treatment:

1.liquid diet and oral fluids.

2.INJ.pan 40mg/iv/od at 7am 

3.INJ.zofer 4 mg/ iv /bd 

5.INJ.Tramadol 100mg in 100 ml NS/iv/sos

6.strict I/O charting

7.IVF-1 NS,1 DNS,2 RL


SUMMARY:

Diagnosis:

Acute interstitial pancreatitis.

History:

52 year old male shepherd by occupation came to OPD with cheif complaints of

-Pain abdomen since 3 days 

-1 episode of vomitings ( 2 days back ) 

GENERAL EXAMINATION:

Patient is conscious coherent and cooperative 

No pallor ,icterus , clubbing,cyanosis,lymphadenopathy ,pedal edema

BP- 110/70mmhg

PR -90bpm

RR-18cpm

Spo2 99% at room air 

GRBS - 91mg/dl

SYSTEMIC EXAMINATION:

CVS: s1,s2 heard ,no Murmurs,jvp not raised 

RS: BAE,no added sounds ,NVBS, 

P/A: soft, non tender,bowel sounds can be heard 

CNS:

Pt is conscious

Speech is normal

No meningeal signs

Normal cranial nerve examination, motor system, sensory system

GCS: E4,V5,M6

Reflexes:


       R       L


B  ++      ++


T   ++       ++


S  ++       ++


K ++     ++


A   ++    ++


P  Flexor   Flexor  

Course in the hospital:

Patient was investigated further and treated conservatively and then pain decreased,was allowed liquid diet then soft diet and pain abdomen completely resolved.Patient was counselled for alcohol abstinence and was discharged in stable condition.

Advice:

Tab.Pan 40MG PO/OD

Tab.Befothiamine 100MG PO/OD x5 days

Tab.Neurobion forte PO/OD

Plenty of oral fluids



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