47 year old with pain abdomen

CBBLE UDHC SIMILAR CASES

 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 47 year old lorry driver  came with c/o pain abdomen since today 3 am (23/2/2022).

Hopi:

Patient was apparently  asymptomatic 14 years back, went to hospital for regular check up and was diagnosed with DM -2  and since then he is on OHA’s , Gilmi M2 po/bd. 

10 years back on routine check up he came to be diagnosed with HTN and he is on TELMA - H / OD . 

20 years back diagnosed with renal calculi ,pain- operated

4.5 years back , patient c/o abdominal full ness , associated with  tightness , squeezing type , relieved with vomitings  associated with  vomitings  bilious  associated with food particles 

Patient is having similar episodes every once in  a year

Patient is chronic alcoholic since 20 -25 years, whiskey ( 90-180 ml) / every day , 4-5 times / week 

Fever , burning micturition since 5 days 

Last binge 4-5 days back , 90 ml whiskey 

No c/o chest pain , palpitations , syncopated attacks

Past history:

k/c/o Dm since 14 years and on tab gilmi - m2 

k/c/o HTN since 10 years and on tab telma-h /OD 

n/k/c/o Tb , bronchial asthma , cad, 

Surgical history: previously had surgery for hernia 

Personal history:

Married 

Lorry driver  by occupation 

Appetite:normal

Bowel bladder movements: regular 

Addictions: alcohol consumption since 20-25 years , whiskey,(90-180 ml)/ every day ,4-5 times / week 

90-180ml ,whiskey per day 

Family history: not significant 

O/e:

Pt is c/c/c,well oriented to time,place,person

No signs of pallor,icterus,clubbing,cyanosis,lymphadenopathy,pedal edema.

Vitals:

Temp:101 F 

Pr:97 bpm 

Rr:17 cpm

Bp:140/100

Grbs:86 mg /dl

Systemic examination:

Cvs: S1,S2 heard

Rs:BAE +

P/A: rigid, tenderness in epigastric region 

Cns: NAD

Investigations:(23/2/2022)

Haemogram:

Hb-15.2

Tlc-10,600

N/L/E/M-87/06/01/06

Pcv -41.5

Plt-1.60

Imp- normocytic normochromic with neutrophilia 

Cue:

Albumin- trace

Sugar- + +

Pus cells- 3-4

Urea - 29

Serum creatinine - 0.9

Sodium -135

Potassium-3.4

Chloride -103

Tb-3.38

Db-1.91

Sgot-328

Sgpt-182

Alkaline phosphate -245

Total proteins-6.4

Albumin-3.9

A/G ratio-1.56

ABG:

Ph- 7.38

PCO2- 23.5

PO2-86.6

HCO3-13.8

 

Serum amylase- 185

Lipase-89

 

Hba1c-6.9 

25/2/22

Tb-3.78

Db-2.82

Sgot-88

Sgpt-101

Alkaline phosphate -225

Total proteins-6.2

Albumin-3.6

A/G ratio-1.41

Haemogram:

Hb-14.7

Tlc-5,100

N/L/E/M-70/18/4/8

Plt-85.4

Imp- normocytic normochromic 

Pt-19

Aptt-38

Inr-1.4

Chest x ray -

Ecg-

Usg- 

Imp-1)Acute on chronic pancreatitis 

        2)Left renal calculi 

Cect abdomen-

Imp-1)chronic calculus pancreatitis 

        2) Bilateral small renal calculi 

        3)Gall bladder wall edema- reactive 

Plan:

1.Ivf with ns and rl @ 100 ml/hr 

2.NBM till further order

3.Inj pan 40mg/iv/bd

4.inj zofer 4mg/iv/tid

5.inj tramadol 1amp in 100ml ns /iv/tid

6.tab telma -h /od 

7.inj thiamine 1amp in 100ml ns/iv/tid

8.inj  hai s/c tid acc to sliding scale 

8.strict input output charting 

Diagnosis: Acute  on chronic pancreatitis with Dm since 14 years  and Htn since 10 years

Amc

DAY 2

47yr/M

https://157divyasri.blogspot.com/2022/02/cbble-udhc-similar-cases_17.html

S :  1 fever spike since yesterday 

       Pain subsided

      

O :

O/E 

Patient is c/c/c

Temp : 98.6 F

PR : 100 bpm

RR : 18cpm

BP : 130/90

Spo2 : 98%at RA

CVS : S1 S2 + , No murmurs 

RS : Bae+

PA :  Soft, non tender  

GRBS :118 mg/dl

              

A : Acute  on chronic pancreatitis with alcoholic liver disease with Diabetes since 14 years  and Hypertension since 10 years

P : 

1.Ivf with ns and rl @ 100 ml/hr 

2.normal diet 

3.Inj pan 40mg/iv/bd

4.inj zofer 4mg/iv/tid

5.inj tramadol 1amp in 100ml ns /iv/tid

6.tab telma -h /od 

7.inj thiamine 1amp in 100ml ns/iv/tid

8.inj  hai s/c tid acc to sliding scale 

8.strict input output charting

DAY 3

Amc

47yr/M

https://157divyasri.blogspot.com/2022/02/cbble-udhc-similar-cases_17.html

S :  pain subsided

       

      

O :

O/E 

Patient is c/c/c

Temp : 98.6 F

PR : 92 bpm

RR : 18cpm

BP : 130/80

Spo2 : 99%at RA

CVS : S1 S2 + 

RS : Bae+

PA :  Soft, non tender  

GRBS :

25/2/22

2pm-127 

8pm-170

26/2/22

2am-125

8am-130

              

A : Acute  on chronic pancreatitis  with Diabetes since 14 years  and Hypertension since 10 years

P : 

1.Ivf with ns and rl @ 100 ml/hr 

2.soft diet

3.Inj pan 40mg/iv/od 

4.inj zofer 4mg/iv/OD

5.inj tramadol 1amp in 100ml ns /iv/sos

6.tab telma -h /od 

7.inj thiamine 1amp in 100ml ns/iv/tid

8.inj  hai s/c tid acc to sliding scale 

8.strict input output charting

DAY 4

Ward

47yr/M

https://157divyasri.blogspot.com/2022/02/cbble-udhc-similar-cases_17.html

S :  pain subsided, no fever spike 

       

      

O :

O/E 

Patient is c/c/c

Temp : 98.9F

PR : 87 bpm

RR : 18cpm

BP : 130/80

Spo2 : 99%at RA

CVS : S1 S2 + 

RS : Bae+

PA :  Soft, non tender  

GRBS :170 

              

A : Acute  on chronic pancreatitis  with Diabetes since 14 years  and Hypertension since 10 years

P : 

1.Ivf with ns and rl @ 100 ml/hr 

2.normal diet 

3.Inj pan 40mg/iv/od 

4.inj zofer 4mg/iv/sos

5.inj tramadol 1amp in 100ml ns /iv/sos

6.tab telma -h /od 

7.inj thiamine 1amp in 100ml ns/iv/tid

8.tab glimi -m2  /od

8.strict input output charting

DAY 5

Ward

47yr/M

https://157divyasri.blogspot.com/2022/02/cbble-udhc-similar-cases_17.html

S :  pain subsided, no fever spike 

       

      

O :

O/E 

Patient is c/c/c

Temp : 98.4F 

PR : 91 bpm

RR : 18cpm

BP : 130/80

CVS : S1 S2 + 

RS : Bae+

PA :  Soft, non tender  

GRBS :

27/2/22- 

8am -170

2pm -373

8 pm - 345

28/2/22 

8am- 194

              

A : Acute  on chronic pancreatitis  with Diabetes since 14 years  and Hypertension since 10 years

P : 

1.Normal diet 

2.tab telma- H /po/od

3.Inj hai 8am. 2 pm.   8 pm 

              12U.    12U.    12U 

4.tab mvt po/od 

5.tab pan 40 mg po/od

DAY 6

Ward

47yr/M

https://157divyasri.blogspot.com/2022/02/cbble-udhc-similar-cases_17.html

S :  pain subsided, no fever spike 

       

      

O :

O/E 

Patient is c/c/c

Temp : Afebrile 

PR : 86 bpm

RR : 16 cpm

BP : 130/90

CVS : S1 S2 + 

RS : Bae+

PA :  Soft, non tender  

GRBS :

28/2/22- 

8am -194

2pm -196 -12U  HAI given 

8 pm - 122- 12U HAI given 

1/3/ 22 

8am- 204 -12 U HAI given

              

A : Acute  on chronic pancreatitis  with Diabetes since 14 years  and Hypertension since 10 years

P : 

1.Normal diet 

2.tab telma- H /po/od

3.Inj hai 8am. 2 pm.   8 pm 

              12U.    12U.    12U 

4.tab mvt po/od 

5.tab pan 40 mg po/od