42 yr old with Pancreatitis

 THIS IS AN 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT

CHIEF COMPLAINTS- 

Pain Abdomen and vomiting since 3 days

HISTORY OF PRESENT ILLNESS: 

He was apparently asymptomatic two years back then he had developed yellow discoloration of the sclera for which he visited a nearby hospital and got treated conservatively (MEDICATION: UDILIV for how many days? INDICATION?) One year back, he again had Sclera, for which the patient took UDILIV and the discoloration decreased.

Ten days back, the Patient had an injury to the right-hand ring finger (laceration of size 1*1cm over the dorsum), due to an accidental hit while working in the carpenter shop. later the injury, the whole hand got swollen. There was mild tenderness all over the hand, and after that, he cannot flex his ring finger. 

Five days back he got a fever associated with chills and rigor, and after consulting a hospital then he started medication (PIPTAZ INJ.) then the fever got subsided and he had no history of weight loss, no diurnal variation.

For three days, he is suffering from continuous hiccups and got relieved temporarily from drinking water and the hiccups continued as soon as he vomited water. For two days he is having Abdominal pain ( Right- upper Abdomen). 

there are at least 15 to 20 vomitings in two days, Non-Bilious Non-projectile food and water as contents.

There is a complaint of decreased urinary output since yesterday and constipation for two days. 

past history:-

diabetic ( type 2) for 5 years under medication (Metformin, Teneligliptin) and is under control.

medication (oral drugs)

not a known case of HTN, epilepsy, CAD, asthma, TB, leprosy..

personal history:- 

appetite - normal

diet - mixed

bowel and bladder - regular

sleep adequate - adequate

addictions - regular (alcohol 180ml since 7 yrs)

no tobacco drug usage 

FAMILY HISTORY:-

no significant family history

Allergic history:- 

not allergic to any kind of drugs or food.

occupational history:-

he is a carpenter

GENERAL EXAMINATION:-

the patient is conscious co-operative and well oriented towards time place and person.

well built and well nourished

VITALS:-

temperature:-Afebrile

pulse rate:- 80 bpm

respiratory rate:-20 CPM

B.P:-120/90 mm Hg

GRBS:- 115 mg%

B.M.I:-?

SPO2:- 99%

No pallor

icterus - present

Cyanosis - No

Clubbing - No

Lymphadenopathy - no

Edema - No 

SYSTEMIC EXAMINATION:-

FOR ABDOMEN:-

The shape of the abdomen - mild distension

Tenderness - present ( Right hypo chondrium, Epigastric region, Left hypo chondrium, Umbilical region)

No palpable masses

No free fluid 

Liver -no hepatomegaly 

Spleen - Not palpable 

Bowel sounds - Normal

RESPIRATORY SYSTEM:- 

Bilateral air entry - Positive

Normal vesicular breath sounds are heard all over the chest

CARDIOVASCULAR SYSTEM:-

S1, S2 - Heard 

No murmurs

CENTRAL NERVOUS SYSTEM:-

Speech - Normal

Cranial nerves - Normal

Motor system - Normal 

Sensory system - Normal

No signs of meningeal irritation 

INVESTIGATIONS:- 

Hemogram- 

ABG:: 

CBP:: 

Blood urea- 

LFT-- 

Serum electrolytes--

Provisional DIAGNOSIS:-

Pancreatitis with AKI, DM for 5 years

TREATMENT:-

Allow only water

INJ- NS, RL _ 100ml | HR

INJ PANTOP 40mg IV | BD

INJ XOFER 4 MG IV | TID

INJ THIAMINE 100mg IV 100ml NS IV | TID

INJ MONOCEF 1gm IV |BD

INJ DOXY 100mg IV| BD

TAB BACLOFEN 10mg PO | BD