40 yrs old male with acute pancreatitis with uncontrolled sugars

 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 a series of inputs available global online community of experts with the aim to solve the patient’s clinical problems with the collective current best evidence based inputs. This E log reflects my patient centred online learning portfolio and your valuable inputs in the comments section.


40year old male who works as a field assistant who is chronic alcoholic came to casualty with complaints of abdominal pain since one day & vomitings since one day 

HISTORY OF PRESENT ILLNESS:

 Patient was apparently asymptomatic 1 day back , since 3 days there is history of binge alcohol consumption (around 450ml(IB) whisky) after which he developed pain abdomen since 1day which was squeezing type,mostly in epigastric region,diffuse type associated with nausea & vomiting 8 to 10 episodes/day which was non bilious, non projectile, water or food as content because vomiting occurs after taking food or water.

No h/o loose stools or constipation 

No h/o fever ,shortness of breath, cough.

PAST HISTORY:

H/o pancreatitis 4 years ago.

He is a known case of diabetes mellitus since 10 yrs, since 1 yr using HAI(human actrapid insulin) 10U in the morning & 5U in the night , before which he was on oral hypoglycemic agents.


He is a known case of hypertension since 10 yrs using T. AMLODIPINE 5mg OD

PERSONAL HISTORY:

Diet:mixed

Appetite:normal

Bowel and bladder: regular

Sleep: adequate

Addictions:alcohol,he takes 180ml whisky every day


FAMILY HISTORY:

No relevant family history


TREATMENT HISTORY

For diabetics he is taking HAI 10U in the morning and 5U in the evening.

GENERAL EXAMINATION:

Patient is conscious ,coherent, coperative ,well oriented to  time place and person.

Moderately built and nourished.

No pallor ,no icterus,no cyanosis,no clubbing,

No Generalised lymphadenopathy ,No pedal edema

Vitals : 

Temp: 98.4 f

HR: 100 bpm

RR : 18cpm

BP : 160/80 mm hg

Spo2: 99 @ RA

GRBS : 397 mg/dl 


SYSTEMIC EXAMINATION : 


CVS : S1 S2 + . 

RS : NVBS + (normal vesicular breath sounds)

PA: diffuse tenderness present, more in left hypochondriac region, epigastric region & left iliac fossa

CNS : NAD 

           




  











DIAGNOSIS : Acute Pancreatitis with uncontrolled sugars 


TREATMENT : 


IVF : NS , RL @ 100ml/hr 

INJ. ZOFER 4mg IV /BD

INJ.PANTOP 40mg IV/OD

INJ. TRAMADOL 1amp in 100ml NS IV/BD

INJ. PIPTAZ 2.25gm IV /QID 

TAB. AMLONG 10mg PO/OD

GRBS monitoring 

INJ. HUMAN ACTRAPID according to sugars 

Inform SOS


INVESTIGATIONS:


               


 



       
         


          

            Chest X-RAY PA view (3/3/22):





             Ecg on 3/3/22:




2-D ECHO (4/3/22)




Ultrasound abdomen &pelvis (3/3/22)


              








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