41 YEAR OLD MALE WITH HIGH COLOURED URINE SINCE 2 YEARS PAIN ABDOMEN SINCE 1 WEEK
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)
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41yr old male pt came to casuality on 25/2/21 at 7 pm with c/o high coloured urine since 2 yeara
c/o pain andomen since 2 days
pt was apparently asymptomatic 6years back In 2015 he developed high coloured urine for which he went to the private hsptl and was told that he had ureteric calculi(no medical records). later in 2019 he had on and off episodes of high coloured urine weekly twice He was diagnosed with hypertension in 2019 for which he took medication only for 1 week and then when he went for regular checkup in 2020 again as his bp recordingwere high he was pescribed nedication which he used only for 1 week.
c/o pain abdomen 1 week which was Diffuse, continuous, squeezing type,aggravated on eating food.
No H/o loose stools and vomitings, No H/o fever .pt was hospitalized and recevied treatment for the same 6 month ago
Past history
k/C/O HTN since 2Years not on any medication
Not a k/c/o DM, Epilepsy, Asthma, thyroid disorder
Cholecystectomy was done 1 year back
personal history
Alcoholic since 7 years[120/ml daily since 1 year]
H/o smoking 10 year back
o/e
pt is conscious coherent cooperative
No signs pallor ,cyanosis clubbing ,lymphadenopathy ,pedal edema
vitals
Temp-afebril
PR-110bpm
BP-180/120mmhg
GRBS-150mg/dl
spo2-98%at RA
Systemic Examination
CVs-s1,s2 +
RS-BAE+
P/A
Abdomen obese
Lap cholecystectomy scar +
No visible peristalsis
All quadrants moving equally with respiration
Palpation
No local rise of temperature
Tenderness present in the epigastrium ,right and left hypochondrium
No rigidity
Guarding present in epigastrium and right hypochondrium
Provisional Diagnosis
ACUTE PANCREATITIS
Investigations
ON THE DAY OF ADMISSION
Treatment
1.IVF @100ml/hr
2.INJ PAN 40 MG IV/OD
3 INJ ZOFER 4MG/IV/ OD
4.INJ OPTINEURON IV/OD
5.INJ TRAMADOL 1 AMP IN 100ml NS/IV/SOS
6.RYLES TUBE INSERTION
DAY 1(26/2/21)
1.IVF(NS DNS)@100ML/HR
2.INJ PAN 40 MG IV/OD
3 INJ ZOFER 4MG/IV/ OD
4.INJ OPTINEURON IV/OD
5.INJ TRAMADOL 1 AMP IN 100ml NS/IV/SOS
6.RYLES TUBE INSERTION
DAY2(27/2/21)
1.IVF(NS DNS)@100ML/HR
2.INJ PAN 40 MG IV/OD
3 INJ ZOFER 4MG/IV/ OD
4.INJ OPTINEURON IV/OD
5.INJ TRAMADOL 1 AMP IN 100ML NS/IV/SOS
6.SYP CREMAFFIN PLUS 15ML/PO/TID
DAY 3(28/2/21)
Pain subsided
1)ORAL FLUIDS
2.INJ PAN 40 MG IV/OD
3 INJ ZOFER 4MG/IV/ OD
4.INJ OPTINEURON IV/OD
5.INJ TRAMADOL 1 AMP IN 100ML NS/IV/SOS
6.SYP CREMAFFIN PLUS 15ML/PO/TID
DAY4(1/3/21)
S-C/o high coloured urine since 2 years
O-On examination
Bp-160/90mm hg
PR-88bpm
RR-16cpm
CUE- RBC- plenty
Albumin +++
Pus cells -plenty
A - acute pancreatitis with urinary tract
P- TREATMENT GIVEN
1)ORAL FLUIDS
2.INJ PAN 40 MG IV/OD
3 INJ ZOFER 4MG/IV/ OD
4.INJ OPTINEURON IV/OD
5.INJ TRAMADOL 1 AMP IN 100ML NS/IV/SOS
6.SYP CREMAFFIN PLUS 15ML/PO/TID
7)SYP CITRALKA 15ML PO/BD
8) TAB NITROFURANTOIN 100MG/PO/BD
9)TAB TELMA 40MG /PO/OD
DAY 5(2/3/21)
BURNING MICTURITION SLIGHTLY DECREASED AND HEMATURIA PRESENT
acute pancreatitis with urinary tract
P- TREATMENT GIVEN
1)ORAL FLUIDS
2.INJ PAN 40 MG IV/OD
3 INJ ZOFER 4MG/IV/ OD
4.INJ OPTINEURON IV/OD
5.INJ TRAMADOL 1 AMP IN 100ML NS/IV/SOS
6.SYP CREMAFFIN PLUS 15ML/PO/TID
7)SYP CITRALKA 15ML PO/BD
8) TAB NITROFURANTOIN 100MG/PO/BD
9)TAB TELMA 40MG/PO/OD
Diagnosis- ACUTE PANCREATITIS (RESOLVED) WITH CHRONIC GLOMERULONEPHRITIS
