General Medicine e-log book by Neeha sruthi

Case of a 29 year old male patient with Acute on Chronic Pancreatitis

This is the online e-log book to discuss about patient.The de-identified health data shared after taking his/her/Guardian signed informed consent.Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patient’s clinically problems with collective current best evidence based inputs”. 

Case History :

A 29 year old male patient presented to the casualty on 10th June with chief complaints.

Chief Complaints :

1. Pain abdomen since morning

2. Vomiting since morning

History of Presenting Illness :

Patient was apparently asymptomatic 3 years back, then he was diagnosed with Acute Pancreatitis in 2018 and there was a 2nd episode in March, 2020. 

On the day of admission, the patient had a heavy meal in the morning after which he developed pain abdomen which was sudden in onset, gradually progressive, non radiating and has no aggravating or relieving factors. There is also history of vomiting which was 2 episodes since morning and 3 episodes after presentation. The vomiting was non-bilious and non-projectile.

History of Past Illness :

The patient is a known case of Pancreatitis with an history of 2 episodes in 2018 and 2020.

He is not a known case of Type 2 Diabetes mellitus, Hypertension, Asthma, Tuberculosis, Epilepsy.

Personal History :

Diet : Mixed

Appetite : Decreased

Bowels : Regular

Micturition : Normal

Addictions : Rebound drunker since 2020; History of alcohol intake since 3 years with a frequency of 3-4 times per week

Allergies : None

Family History :

There is no significant family history.

General Examination :

The examination was done after obtaining informed consent in a well lit room.

Patient was conscious, coherent and co-operative and is well oriented to time, place and person.

He is well nourished and moderately built.

There was no pallor, icterus, cyanosis, clubbing, lymphadenopathy and pedal edema.

Vitals :

At the time of admission :

Temperature : 98.6^° F

Pulse Rate : 98 beats per minute

Blood Pressure : 120/60 mm Hg

Respiration rate : 18 breaths per minute

SpO2 : 98% on room air

RBS : 103 mg/dl

Systemic Examination :

Respiratory System : BAE +

Cardiovascular System : S­₁,S₂ heard

Per Abdomen : Tenderness observed on deep palpation around the umbilical

CNS Findings : Normal

Investigation:

Ultrasound abdomen:

Diagnosis :

Acute on Chronic Pancreatitis

Treatment :

1. Nasogastric Feed 

2. Inj. Pantoprazole 40 mg IV OD

3. Inj. Zofer 4 mg IV TID

4. Inj. Tramadol 1 Amp in 100 ml NS IV BD

5. BP Charting - 8th hourly

6. Strict I/O charting

Summary:

A 29 year old patient admitted to the casualty on 10th June with some chief complaints like pain abdomen since morning and vomiting since morning.

Dr. Meghana Andem has assisted the case and provided the family history details of the patient.

Patient was apparently asymptomatic 3 years back, then he was diagnosed with Acute Pancreatitis in 2018 and there was a 2nd episode in March, 2020. 

On the day of admission, the patient had a heavy meal in the morning after which he developed pain abdomen which was sudden in onset, gradually progressive, non radiating and has no aggravating or relieving factors. There is also history of vomiting which was 2 episodes since morning and 3 episodes after presentation. The vomiting was non-bilious and non-projectile.

Patient’s past history shows relative symptoms for the cause of symptoms like Pancreatitis with an history of 2 episodes in 2018 and 2020.

He is not a known case of Type 2 Diabetes mellitus, Hypertension, Asthma, Tuberculosis, Epilepsy.

The general examination was Patient was conscious, coherent and co-operative and is well oriented to time, place and person.

He is well nourished and moderately built.

There was no pallor, icterus, cyanosis, clubbing, lymphadenopathy and pedal edema.

Diagnosis :

Acute on Chronic Pancreatitis

Treatment :

1. Nasogastric Feed 

2. Inj. Pantoprazole 40 mg IV OD

3. Inj. Zofer 4 mg IV TID

4. Inj. Tramadol 1 Amp in 100 ml NS IV BD

5. BP Charting - 8th hourly

6. Strict I/O charting