A 55 YEAR OLD MALE WITH ACUTE PANCREATITIS

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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.

Date of admission:31-10-2022


CHIEF COMPLAINT:
58yr old male patient ,he's a cook by occupation came to casuality with a C/O pain in upper abdomen, with vomitings since yesterday morning.

HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic upto yesterday 
Later he developed pain in upper abdomen Which was sudden in onset Progressive and non radiating and not relieved on medication.
H/O Vomiting since today mrng 5-6 episodes,water as content,non projective ,non bilious
No H/O fever, constipation, loose stools
Patient started drinking alcohol 15yrs back ,he consumes 90ml daily at night. 

HISTORY OF PAST ILLNESS:
N/K/C/O HTN,DM,CAD,TB,epilepsy,Asthama
No past surgical history 

PERSONAL HISTORY:
Appetite-normal
Diet-mixed
Bowel and bladder Movement-Regular
No allergies 
Alcoholic regularly


 
GENERAL EXAMINATION:
patient is Conscious,coherent and cooperative 

-No pallor

-No icterus

-No lymphadenopathy

-No cyanosis

-No clubbing of fingers 

VITALS:
Temperature-afebrile
Pulse rate -90 bpm
Respiration rate -16cpm
Bp-110/80 mm Hg
Spo -98%

SYSTEMIC EXAMINATION:
▪️CVS

S1 & S2 sounds are heard

▪️ RESPIRATORY SYSTEM

-BAE present


INVESTIGATIONS 
Serum creatinine -0.9
Blood urea- 20mg/dl
Serum electrolytes:
Sodium-137
Potassium-4
Lipase-29
Amylase- 84



DIAGNOSIS:
ACUTE PANCREATITIS

TREATMENT:
Inj PAN 40mg IV /OD
Inj BUSCO PAN  IM

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