50 year Old male with abdominal Pain

Jan 02 2023

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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT

A 50 year old male came to opd with 
Chief complaints of abdominal pain since 12 am of 2/1/23.

History of presenting illness
Patient was asymptomatic 1 day ago ,then he developed abdominal pain which is insidious in onset ,gradually progressive in nature ,colicky pain

Pain is continuous and diffuse all over abdomen,more felt in epigastrium.
No aggravating and relieving factors.

No history of radiating pain to back ,nausea,vomiting , constipation ,blood in stools ,loose stools.

He is a chronic alcoholic of 30 yrs

Past history
H/O of diabetes since 3yrs on medication
No h/o of hypertension ,tb,asthma,epilepsy.

Personal history

Daily routine:
He wakes up at 8 am and does his daily routine and is not working ,takes 3 meals daily and drinks alcohol and smokes intermittently through the day and sleeps by 10 pm.

Diet- mixed
Appetite -normal
Bowel and bladder -regular
Sleep-disturbed since yesterday
Addictions -alcohol of 180 ml daily on average
 cigarette {tobacco} of 2 to 3 packs daily since 30 yrs

Family history:. Not significant

Treatment history:on anti diabetic medication since 3 yrs

GENERAL PHYSICAL EXAMINATION
Patient is conscious , coherent and co operative 
 
No pallor
     Icterus
     Clubbing
     Cyanosis
      Lymphadenopathy
     Generalised edema
Vitals 
     Temp - 37℃
     Blood pressure -150/100 mmHg
      Pulse rate- 65 bpm
       Respiratory rate- 20 bpm

Systemic examination

Per abdomen examination

 On Inspection 
Abdomen is obese
Umbilicus is central and inverted
No visible scars/sinuses/engorged viens
 All quadrants are moving Uniformly on respiration
Grey turner sign ( discolouration of flanks) and Cullens sign( discolouration of periumbilical area ) are negative [ These are +ve in patients with severe pancreatitis with Haemorrhage ]
On palpation
Inspectory findings are confirmed
Tenderness is seen in epigastrium, left lumbar ,umblical region
No guarding,no rigidity,
No hepatosplenomegaly
 
On percussion
Liver span is normal

On auscultation
Bowel sounds are heard
   
CVS examination
 S1,S2 heart sounds are heard

  Respiratory system examination;
     Bilateral normal vesicular breath sounds heard
    
  CNS examination
    No focal neurological deficits

Investigations:
Hemogram:
Liver function test:
Serum lipase:
Serum amylase:
X ray erect abdomen 
CECT:

Provisional diagnosis:-
Acute pancreatitis
Treatment 
On 2 /1/23  
Ini pantoprazole 40mg iv 
Inj zofer 4mg iv stat
Ini diclofenac im stat
Ini buscopan 40 mg im stat

 NBM till further
Iv fluids NS ,NL. 100ml/hr
Ini pantoprazole 40 mg iv od
Inj tramadol 1 amp in 100ml NS sos
Inj thiamine 100 mg in 100ml NS/IV/TID
CUBICAL : 2
Day 2  
Unit 1

Dr. Zain (SR)
Dr. Raveen(PGY3)
Dr. Chandana(PGY3)
Dr. Vivek(PGY1)
Dr. Prachethan (PGY1)
Dr.Nagarjuna ( intern)
Dr.kausalya (intern)

S 
No fever spikes
C/O pain abdomen pain Decreased
Stools not passed ,passing flatus 


O
Patient conscious, coherent,cooperative 
Temp: 98F
BP:180/110 MMHG
PR:88 BPM
RR:16CPM
CVS :S1,S2 +
RS: BAE+
CNS: NFND
Lungs : B/L air entry +
              NVBS +
P/A soft tenderness+ in epigastrium,Rt lumbar, L lumbar

A
Acute pancreatitis secondary to alcohol intake 

P
1 NBM TILL FURTHER ORDERS 
2 IV FLUIDS 2 NS 2 RL@ 100 ml/hr
3 INJ PAN 40 MG IV /OD/BBF
4 INJ THIAMINE 200MG+ 100 ML NS/IV/TID 
5 GRBS 7 PROFILE MONITORING 
6 INJ HAI SC/TID/PREMEAL ACCORDING 
TO S/S
     




     

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