A case of acute pancreatitis

-
A 55Y old male came to casuality with chief complaints of  
_ pain abdomen( generalised) since 3 days associated with distention and tigheting
_ vomitings( non projectile and non bilious) since 2 days and subsided.

HOPI:
  Pt. was apparently asympomatic 2 years ago then had complaints of abdominal pain with distention for which he went to hospital and took medication and got relieved.Then again  3 days back then developed pain abdomen which was generalised and associated with distention and tigheting.
Vomitings since 2 days which got subsided.
 - No H/o fever, headache, diarrhea.
-  H/o alcohol intake 2 days back.

Past history:
No H/O of DM, HTN, asthma, TB, epilepsy
Had laparotomy 25 years back
H/O pancreatitis 2 years ago.

Family history: NAD

Personal history:
Apetite : normal
Diet: mixed
Bowel and bladder: regular 
Sleep : adequate
Addictions: alcohol intake since 20 years, occasionally

General examination:
Patient was C, C, C
No pallor, cyanosis, clubbing, edema, lymphadenopathy.

VITALS :
PR - 120 bpm
BP - 80/50 mmhg
RR - 21 cpm
TEMP - AFEBRILE

SYSTEMIC EXAMINATION :
CVS - S1, S2 heard, no murmurs
RS - BAE
P/A - Soft , Non tender
CNS - NAD

PROVISIONAL DIAGNOSIS:
Acute on chronic pancreatitis secondary to alcoholism with cholithiasis

INVESTIGATIONS:
ECG:
Investigations ( outside our hopsital)
on 18/6/21
on 19/6/21
USG:

TREATMENT:

ON  19/06/2021:
- IVF 1 NS ,1 RL @ 150 ML PER HOUR
-INJ PAN 40 MG IV/OD
-INJ. ZOFER 4MG IV//BD
-INJ TRAMADOL 1 AMP IN 100 ML NS IV/SOS
-INJ OPTINEURON 1 AMP IN 100 ML NS IV/OD
-BP,PR,TEMP CHARTING
-RYLES TUBE INSERTION
-FOLEYS INSERTION
-INJ KCL 1 AMP IN 800 ML NS @ 100 mL/hr

ON 20/06/2021
IVF 1 NS ,1 RL @ 150 ML PER HOUR
INJ PAN 40 MG IV/OD
INJ. ZOFER 4MG IV//BD
INJ TRAMADOL 1 AMP IN 100 ML NS IV/SOS
INJ OPTINEURON 1 AMP IN 100 ML NS IV/OD
BP,PR,TEMP CHARTING
INJ THIAMINE 100 MG IN 100 ML NS
INJ KCL 1 AMP IN 800 ML NS @ 100 ML PER HOUR
STRICT I/O CHARTING


ON 21/06/2021
IVF 1 NS ,1 RL @ 150 ML PER HOUR
INJ PAN 40 MG IV/OD
INJ. ZOFER 4MG IV//BD
INJ TRAMADOL 1 AMP IN 100 ML NS IV/SOS
INJ OPTINEURON 1 AMP IN 100 ML NS IV/OD
BP,PR,TEMP CHARTING
INJ THIAMINE 100 MG IN 100 ML NS
INJ KCL 1 AMP IN 800 ML NS @ 100 ML/HR
STRICT I/O CHARTING


ON 22/06/2021
 ORAL FLUIDS 4 LIT PER DAY ,SOFT ORAL DIET
 INJ PAN 40 MG IV/OD
 INJ. ZOFER 4MG IV/BD
 INJ TRAMADOL 1 AMP IN 100 ML NS IV/SOS
 INJ OPTINEURON 1 AMP IN 100 ML NS IV/OD
 BP,PR,TEMP CHARTING
 INJ THIAMINE 100 MG IN 100 ML NS
 INJ KCL 1 AMP IN 800 ML NS @ 100 ML/HR
 STRICT I/O CHARTING.

DISCHARGE SUMMARY:

Discharge Date
Date:23/06/2021
Ward:MALE WARD GM
Unit:6
Name of Treating Faculty
Treating faculty: 1) Dr Arjun Kumar ( Asst prof)2) Dr Ajith Kumar ( PGY2)3) Dr Durga Krishna
(PGY1)4) Dr Keerthi(Intern)5) Dr Sreeja(Intern)6) Dr Sriya(Intern) 7) DR. VAISHNAVI(INTERN)
8) DR. SHREYA( INTERN)
Diagnosis
ACUTE ON CHRONIC PANCREATITIS
Case History and Clinical Findings
55Y old male came to casuality with chief complaints of _ pain abdomen( generalised) since 3 days
associated with distention and tigheting_ vomitings( non projectile and non bilious) since 2 days and
subsided.HOPI: Pt. was apparently asympomatic 2 years ago then had complaints of abdominal pain
with distention for which he went to hospital and took medication and got relieved.Then again 3 days
back then developed pain abdomen which was generalised and associated with distention and
tigheting.Vomitings since 2 days which got subsided.- No H/o fever, headache, diarrhea.- H/o alcohol
intake 2 days back.Past history:No H/O of DM, HTN, asthma, TB, epilepsyHad laparotomy 25 years
backH/O pancreatitis 2 years ago.Family history: NADPersonal history:Apetite : normalDiet:
mixedBowel and bladder: regular Sleep : adequateAddictions: alcohol intake since 20 years.

Investigation: 
USG: 
BILATERAL GRADE 1 RPD
LEFT SIMPLE RENAL CYSTS
ECG
 COMPLETE URINE EXAMINATION (CUE) 19-06-2021 05:11:PM
 COLOUR Pale yellow
 APPEARANCE Clear
 REACTION Acidic
 SP.GRAVITY 1.010
 ALBUMIN +
 SUGAR Nil
 BILE SALTS Nil
 BILE PIGMENTS Nil
 PUS CELLS 3-6
 EPITHELIAL CELLS 2-3
 RED BLOOD CELLS Nil
 CRYSTALS Nil
 CASTS Nil
 AMORPHOUS
DEPOSITS
Absent
OTHERS Nil
BLOOD UREA  : 48 mg/dl( 42-12 mg/dl)
SERUM CREATININE: 1.7 mg/dl (1.3-0.9 mg/dl )
SERUM ELECTROLYTES (Na, K, C l) 
 SODIUM 134 mEq/L( 145-136 mEq/L)
 POTASSIUM 3.2 mEq/L( 5.1-3.5 mEq/L)
 CHLORIDE 102 mEq/L (98-107 mEq/L)
HBsAg-RAPID Negative 
Anti HCV Antibodies :Non Reactive Kit
COMPLETE BLOOD PICTURE (CBP) :
 HAEMOGLOBIN 12.0 gm/dl 17.0-13.0 gm/dl
 TOTAL COUNT 10600 cells/cumm 10000-4000
cells/cumm
 NEUTROPHILS 86 % 80-40 %
 LYMPHOCYTES 09 % 40-20 %
 EOSINOPHILS 02 % 6-1 %
 MONOCYTES 03 % 10-2 %
 BASOPHILS 00 % 2-0 %
 PLATELET COUNT 1.50
 SMEAR Normocytic
normochromic with
relative neutrophilia
 SERUM ELECTROLYTES (Na, K, C l) 21-06-2021 11:35:AM
 SODIUM 138 mEq/L 145-136 mEq/L
 POTASSIUM 3.7 mEq/L 5.1-3.5 mEq/L
 CHLORIDE 99 mEq/L 98-107 mEq/L

Treatment Given(Enter only Generic Name)
On 19/6/21:
IVF 1 NS ,1 RL @ 150 ML PER HOUR
INJ PAN 40 MG IV/OD
INJ. ZOFER 4MG IV//BD
INJ TRAMADOL 1 AMP IN 100 ML NS IV/SOS
INJ OPTINEURON 1 AMP IN 100 ML NS IV/OD
BP,PR,TEMP CHARTING
RYLES TUBE INSERTION
FOLEYS INSERTION
INJ KCL 1 AMP IN 800 ML NS @ 100 ML PER HOUR

ON 20/06/2021
IVF 1 NS ,1 RL @ 150 ML PER HOUR
INJ PAN 40 MG IV/OD
INJ. ZOFER 4MG IV//BD
INJ TRAMADOL 1 AMP IN 100 ML NS IV/SOS
INJ OPTINEURON 1 AMP IN 100 ML NS IV/OD
BP,PR,TEMP CHARTING
INJ THIAMINE 100 MG IN 100 ML NS
INJ KCL 1 AMP IN 800 ML NS @ 100 ML PER HOUR
STRICT I/O CHARTING

ON 21/06/2021
IVF 1 NS ,1 RL @ 150 ML PER HOUR
INJ PAN 40 MG IV/OD
INJ. ZOFER 4MG IV//BD
INJ TRAMADOL 1 AMP IN 100 ML NS IV/SOS
INJ OPTINEURON 1 AMP IN 100 ML NS IV/OD
BP,PR,TEMP CHARTING
INJ THIAMINE 100 MG IN 100 ML NS
INJ KCL 1 AMP IN 800 ML NS @ 100 ML PER HOUR
STRICT I/O CHARTING

ON 22/06/2021
ORAL FLUIDS 4 LIT PER DAY ,SOFT ORAL DIET
INJ. ZOFER 4MG IV//BD
INJ TRAMADOL 1 AMP IN 100 ML NS IV/SOS
INJ OPTINEURON 1 AMP IN 100 ML NS IV/OD
BP,PR,TEMP CHARTING
INJ THIAMINE 100 MG IN 100 ML NS
INJ KCL 1 AMP IN 800 ML NS @ 100 ML PER HOUR
STRICT I/O CHARTING

COURSE IN THE HOSPITAL:
A 55Y old male with pain abdomen and vomitings since 3 days , patient was admitted and based on
the ivnvestigations done outside , his serum amylase was very high and ultasound which showed heterogenous echotexture and mildly dialated pancreatic duct and patient having an episode of pancreatitis 2 y back, so the diagnosis of acute pancreatitis was made clinically and radiologically. patient was treated wih IV fluids for rehydration and nutrition,  Inj. zofer once for episode of vomiting, Inj. pan Inj. tramadol sos for his pain. His pain abdomen and vomitings were relieved and became symptomatically better and asked to follow up after 2 weeks

Advice at Discharge
`1)Tab. Ulracet 1/2 tab PO/SOS
2)Tab. Zofer 4mgPO/SOS
3)Tab. Zincovit PO/OD for15 days
4)Tab. pan 40mgPO/OD
5)oral fluids 4-5 L
6)soft oral diet
7) Avoid alcohol
Follow Up After 14 days

When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.

Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:
08682279999 For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed
and the advice regarding preventive aspects of care ,when and how to obtain urgent care have beenexplained to me in my own language .




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