36YEAR OLD MALE WITH ACUTE PANCREATITIS

Interns
Mohitha
M Supriya
K Soumya
Sanjay
Amrutha

PG
Dr Durga krishna PGY1
Dr Ajith Kumar PGY2
Dr Laxma Reddy PGY3
Dr Manasa PGY3
Dr Vijayalakshmi (asst proff)

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 patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

36year old male auto driver by occupation
C/O pain abdomen(diffuse) since 2 days
C/o abdominal distension since 2 days
1 episode of vomiting in the morning
Belching since 2 days 
HOPI
Patient was apparently alright 2 days back 
Then he took alcohol of about 300ml ,followed which he developed pain adbomem which was sudden onset,progressive , continuous ,not radiating ,no aggravating relieving factors
H/O vomiting 1 episode yesterday morning 
Non bilious 
H/o loss of appetite from 2 days
H/OBelchingBelchingBelching since 2 days and SOB since 2 days
No h/o tachycardia ,palpitations,decreased urine output
H/O similar complaint 2 years back when he had pain abdomen on consumption of alcohol and was admitted to private hospital
Not a k/c/o DM , HTN,asthma,epilepsy,CAD
H/O appendicectomy 5 years back

Personal history
Drinks ocassionally 
Tobacco - 2 cigarettes /day since 10 years
Gutka -chews daily since 10 year

O/E
Patient conscious ,coherent,cooperative
Vitals-temp- afebrile Bp-140/90mm hg
PR-94bpm,SpO2-99%at RA
S/E
CVS-s1s2+
RS-BAE+
P/A
Inspection-abdomen distended,umbilicus central,inverted,no engorged veins,no visible pulsations, appendicectomy scar present in RIF
Palpation-No local rise of temperature ,diffuse  tenderness in all quadrents ,no palpables swellings
Percussion-tympanic
 Auscultation- bowel sounds heard



Diagnosia- ?acute pancreatitis 
Treatment 
1)NBM
2)IVF -RL ,DNS@100ml/hr
3)Ryles tube inserted
4)Ing PAN 40mg/IV/OD
5)Inj TRAMADOL1 AMP IN 100ml NS IV/OD
6)Inj ZOFER 4mg IV/OD

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