MEDICINE CASE DISCUSSION

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Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence based input

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 diagnosis and treatment plan.

UNIT 5 ADMISSION 

 32 year old male came to the casualty with clo Pain abdomen in epigastim ,left hypochondrium Since 1 day.

C/o vomiting since 1day (non-billious,non projectile) 2episodes ,containing food-particles

Passing flatus, constipation since 1day morning

Loss of appetite+

No c/o fever

HISTORY OF PAST ILLNESS :

not a K/c/o DM HITN, epilepsy,asthma, CVA,CAD .

PERSONAL HISTORY:

Loss of appetite+,takes mixed diet ,bowel and bladder movements were regular .

H/o alcohol consumption(beer) since 5yrs(2times a day) stopped 1 month back. 

ON EXAMINATION:

Patient  is conscious ,coherent ,co-operative 

Temp-98f

PR-90BPM

RR-20CPM

BP-100/70mmhg

GRBS-266MG/DL

Spo2-98@RA

CVS-S1S2+

RS-BAE+,NVBS

P/A-SOFT,NON TENDER,B/S+

CNS-NAD

PROVISIONAL DIAGNOSIS:

ACUTE PANCTREATITIS SECONDARY TO ALCOHOL

INVESTIGATIONS:

TREATMENT:

1)IVF- NS,RL-150ML/HR

2)INJ.PAN.40MG/IV/BD

3)INJ. THIAMINE 200MG IN 100ML NS /IV/BD

4)INJ.OPTINEURON 1AMP IN 100ML NS/IV/OD

5)INJ.TRAMADOL 1AMP IN 100 ML NS/IV / BD

6)INJ .ZOFER 4MG /IV/BD

7)strict I/O monitoring 

8)BP,PR,SPO2 Monitoring 4th helt

9)GRBS monitoring 6hrly

 SOAP NOTES DAY-2

S: No fresh complaints

Pain abdomen decreased

O:

PR: 82bpm

Bp: 130/80mmhg

Temp: 99F

RR:18cpm

Cvs:s1,s2heard

Rs:BAE+

CNS:NFD 

GRBS :157 mg/dl

A:

Acute pancreatitis secondary to alcohol with denovo diabetes

P:

1)IVF :NS and RL 100 ml /hr

2)INJ pantop 40 mg IV BD

3)INJ.THIAMINE 200MG IN 100ML NS IV/OD (OVER 30MIN)

4)INJ.TRAMADOL 1AMP IN 100ML NS IV/SOS

5)INJ.ZOFER 4MG IV/BD

6)INJ.HAI S/C,acc to GRBS

7)BP,TEMP MONITORING