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26 yr old male with acute pancreatitis

This is 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 patients’ clinical problems with collective current best evidence-based inputs. 



 A 26 yr old male, resident of chityala, car driver by occupation, was presented to the casualty with chief complaints of

CHIEF COMPLAINTS:

  • Abdominal pain since 5 days 
  • Vomitings for 5 days
HISTORY OF PRESENT ILLNESS 

the patient was apparently asymptomatic 4 months ago when he consumed alcohol regularly for a week following which he developed abdominal pain associated with vomitings.then went to a hospital where he was diagnosed with acute pancreatitis. Later he was fine and was discharged.but then he started consuming toddy regularly, 1L per day.

5 days ago, he developed pain in right epigastric and hypochondriac region of abdomen which was associated with 4-5 episodes of vomitings which was yellowish and blood was not present. The pain was of burning type, continuous, non radiating, aggravated after consuming food.

PAST HISTORY 

Not k/c/o DM

not k/c/o HTN

No h/o surgeries in the past

PERSONAL HISTORY 

History of alcohol consumption since 10 years

No h/o smoking 

Sleep: adequate 

Appetite: normal 

B&B regular 

Diet: mixed

No known allergies 

FAMILY HISTORY 

no significant family history 

EXAMINATION 

GENERAL EXAMINATION 

Patient was conscious, coherent and co operative.

moderately built and nourished

No pallor

No cyanosis

No clubbing 

No lymphadenopathy 

No icterus




VITALS

BP 110/70

Pulse 78 bpm

Respiratory rate 16/min

SYSTEMIC EXAMINATION 

CVS

S1 S2 Heard

No thrills

No murmurs 

RESPIRATORY 

no dyspnoea

No wheeze 

Position of trachea central

Vesicular breath sounds heard

ABDOMEN 

TENDERNESS, present- epigastric & rt hypochondriac region of abdomen 

Spleen & liver non palpable 

Bowel sounds heard



















INVESTIGATIONS 









PROVISIONAL DIAGNOSIS 

Acute pancreatitis 


TREATMENT 

23/06/22

IVF NS RL 100ml/hr

Inj. Tramadol 50mg in 100ml IN NS/ IV BD

inj. Pan 40mg IV OD

Inj Zofer 4mg IV TID


24/06/22


IVF NS RL 100ml/hr

Inj. Tramadol 1 Amp in 100ml / IV BD

inj. Pan 40mg IV OD

Inj Zofer 4mg IV TID

Tab pancreo flat PO/OD

25/7/22, 26/7/22 & 27/7/22

IVF NS RL 100ml/hr

Inj. Tramadol 50mg in 100ml / IV BD

inj. Pan 40mg IV OD

Inj Zofer 4mg IV TID

Tab pancreo flat PO/OD


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