MEDICINE E LOG AMITESH

37 yr Male Auto Driver By Occupation Came With Cheif Complaints Of Pain Abdomen March 17, 2022 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 patients clinical problems with collective current based inputs. 37 yr Old Male Auto Driver By Occupation Came to Casualty with C/o Pain In the Epigastric Region since 1 AM ( 16/03/22 ) HOPI :- Patient Was Apparently Asymptomatic Till yesterday Night Then He Noticed Pain In The Epigastric Region At 1 AM after Passing Stools After Waking Up From The Bed ( After Decreased Alcohol Sedation Consumed Last Night , 180 Ml Whisky ). Then The Pain Was Gradually Increased to Severity in The Morning 6 AM , Squeezing Type Radiating To the Back , Associated With Vomitings ( 3 Episodes in A Day ) food Particles As Content , Non Bilious , Non Projectile . Pain Aggravated While Sitting , and Decreased on Sleeping in Right Lateral Position Patient Also Noticed Pain in the Left hypochondrium and Thought To be Heart Problem and Approached Nearest Cardiologist In Nalgonda . Cardiologist Said , There is No Problem Related to the Heart and Advised Admission In Some Other Hospital For The Pain The Patient Was Complaining . The Patient Came To our hospital for Further evaluation and Treatment . PAST HISTORY :- Known case of Hypertension Since 3 months ( Diagnosed In the Government Hospital And Advised To Take Medication , Pateient used Medication for A Week and Then Stopped .) No Similar complaints In the past . No H/o DM, TB , Epilepsy , Asthma. TREATMENT HISTORY : 4years Back the Patient Said to taken Treatment For Urinary tract infection in our hospital and Symptoms Were Releived. ADDICTIONS :- 1) Alcohol - Consuming Whiskey Daily Evening Quantity 180 ML , Since 15 years. 2) Cigarette - Smokes 4-5 Ciggerates / Day Since 10 years. 3) Gutka - consumes 10-15 Packs / day Since 10 years. GENERAL EXAMINATION :- NO Pallor , Icterus , Cyanosis , Clubbing ,lymphadenopathy. Vitals Temp - afebrile BP - 160/100 mm hg PR - 89 bpm. RR - 19 cpm spo2 100 @RA GRBS - 158 mg/dl @ 8 am CVS - S1, S2 heard RS. :- bae present P/A: soft , tender , Guarding Present CNS :- NAD INVESTIGATIONS Serum Lipase - 94 Serum Amylase - 268 HAEMOGRAM Haemoglobin - 19.7 Total Count - 10,700 RBC - Platelet Count - 2.35 RFT S Urea - 12 S Creatinine - 0.9 S Calcium - 9.9 Na - 140 K - 3.7 Cl - 98 LFT Total Bilirubin - Direct Bilirubin - 0.98 Ast - 45 Alt - 34 Alk P - 165 Total Protein - 8.1 Albumin - 4.1 A/G - 1.03 CRP - Positive 2.4 mg/dl HbA1c - 7.0 % Serology - Negative ECG USG abdomen CECT Report PROVISONAL DIAGNOSIS Acute Pancreatitis Treatment 1. Nbm till further orders. 2. IVF- NS & RL @ 100ml/hr. 3. Inj. Pantop 40mg/IV/OD. 4. Inj. Zofer 4mg/IV/SOS. 5. Inj. Tramadol 1amp in 100 ml/NS/IV/BD. 6. Inj. THIAMINE 2amp in 1 NS/IV/TID. 7. Monitor vitals. 8. Measure abdominal girth. SOAP NOTES AMC Day 2 Bed 6 S : C/o Pain Abdomen Decreased O - Patient is conscious,coherent,cooperative vitals : Temp - afebrile BP - 180/100 mm hg PR - 98 bpm. RR - 20 cpm spo2 - 100 @RA GRBS - 154 mg/dl @ am CVS - S1, S2 heard RS - bae present , Decreased Breath Sounds In IAA P/A - Soft , tenderness Present In Umbilical Area bowel Sounds - Sluggish Stools - Not Passed CNS - NAD A - Acute Pancreatitis P - 1. Nbm till further orders. 2. IVF- NS & RL @ 150ml/hr. 3. Inj. Pantop 40mg/IV/OD. 4. Inj. Zofer 4mg/IV/SOS. 5. Inj. Tramadol 1amp in 100 ml/NS/IV/BD. 6. Inj. THIAMINE 2amp in 1 NS/IV/TID. 7. Monitor vitals. 8. Measure abdominal girth. AMC Day 4 Bed 6 S : C/o Pain Abdomen Decreased O - Patient is conscious,coherent,cooperative vitals : Temp - afebrile BP - 140/90 mm hg PR - 82 bpm. spo2 - 98 @RA GRBS - 96 mg/dl @ am CVS - S1, S2 heard RS - bae present , Decreased Breath Sounds In IAA P/A - Soft , no tenderness In Umbilical Area bowel Sounds - Sluggish Stools - Not Passed CNS - NAD A - Acute Pancreatitis with denovo Type 2 Diabetes & Hypertension P - 1. IVF- NS & RL @ 75ml/hr. 2. Inj. Pantop 40mg/IV/OD. 3. Inj. Zofer 4mg/IV/SOS. 4. Inj. Tramadol 1amp in 100 ml/NS/IV/BD. 5. Inj. THIAMINE 2amp in 1 NS/IV/TID. 6. Monitor vitals. 7. Measure abdominal girth. AMC Day 5 Bed 6 S : No Fresh Complaints O - Patient is conscious,coherent,cooperative vitals : Temp - afebrile BP - 180/110 mm hg PR - 94 bpm. RR - 18 cpm spo2 - 100 @RA GRBS - 134 mg/dl @ am CVS - S1, S2 heard RS - bae present P/A - Soft , No tenderness bowel Sounds - Sluggish Stools - Passed CNS - NAD I/O - 1500/1300 ml A - Acute Pancreatitis with denovo Type 2 Diabetes & Hypertension P - IVF- NS & RL @ 75 ml/hr. Inj Pantop 40mg/IV/OD. Inj. Zofer 4mg/IV/SOS. Inj. Tramadol 1amp in 100 ml/NS/IV/ SOS Inj. THIAMINE 2amp in 1 NS/IV/TID. Tab Telma 40 mg Monitor vitals.