This is an online E log book to discuss our patient's de-identified health data shared after taking his /her/guradian's consent.
This E log book also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box below.
This E-log is presented under the guidance of Dr.Vinay(Post graduate) and Dr.Pallavi(intern).
NOTE: This is an ongoing case and will be updated regularly.
A CASE OF CHRONIC PANCREATITIS
The patient was presented to casualty with C/o Abdominal pain,Loss of appetite and Loose stools.
DATE OF ADMISSION: 19/07/2021
CHIEF COMPLAINT:
•Pain in abdomen since the past 20days.
•Loss of appetite since 20 days.
•Loose stools since 1 day.
HISTORY OF PRESENTING ILLNESS:
•The patient has been consuming 90 ml of whiskey, thrice a week since the past 20 years.
•The patient had similar complaints 5 years ago and was diagnosed with pancreatitis for which he received treatment for 1 week.
•On routine investigation, the patient was diagnosed with HTN and diabetes 3 years ago but has been on irregular treatment for the same.
•Since the last 1 year, he has been consuming 180ml of whiskey everyday, last intake was 20 days back.
•Since the past 20 days, he has been experiencing pain in the epigastric region radiating to his right lower back, aggravated on food intake.
•Not associated with vomiting, nausea.
•He was taken to a local hospital outside - where in he was diagnosed with acute on chronic pancreatitis,UTI
with CUE REPORTshowing
10-15 pus cells
Creatinine:2mg/dl
Plateletcount:28,000cells/cumm(low)
for which he was admitted in an outside hospital for 4 days and received medications.
HISTORY OF PAST ILLNESS:
•Patient was diagnosed with HTN and Type 2 DM 3 years ago but has been on a irregular treatment for the same.
•Not a known case of TB,Asthma Epilepsy,CAD,CVA and Thyroid disorders.
PERSONAL HISTORY:
Occupation: coolie
Diet: mixed
Appetite: decreased
Addiction: consumes alcohol
The patient has been consuming 90 ml of whiskey, thrice a week since the past 20 years. Since the last 1 year, he has been consuming 180ml of whiskey everyday, last intake was 20 days back.
DRUG HISTORY:
No known drug allergies
FAMILY HISTORY:
No significant family history.
GENERAL EXAMINATION :
•The patient is conscious, coherent and cooperative.
•Moderatlely nourished and thin built.
•No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy and edema is seen.
VITALS
PR-100bpm
BP-100/70 mmhg
Spo2 - 98% @ room temp
Temperature-Afebrile
SYSTEMIC EXAMINATION:
CNS:
•Speech is normal
•No signs of meningeal irritation
•Motor and Sensory system :Normal
•Cranial nerves :Intact
CVS:
•S1, S2 are heard
No murmurs ;No thrills
RESPIRATORY SYSTEM:
•Trachea-central
•BAE- present
Inspiratory crepts in Bilateral ISA
PER ABDOMEN:
•Diffuse tenderness present
•Mass palpable present in periumbilical region, right lumbar region
•Bowel sounds heard
INVESTIGATIONS:
HEMOGRAM
COMPLETE URINE EXAMINATION
ULTRA SOUND
COLOUR DOPPLER-2D ECHO
ECG
1. IVF - 1NS, 1RL @ 125ml/hr
2. Inj. TRAMADOL 1amp in 100ml NS IV/SOS
3. Inj. PAN 40 mg IV/OD
4. Inj. THIAMINE 1 amp in 100ml NS IV/TID
5. Tab. SPOROLAC DS/ PO/TID
6. Inj. MONOCEF 1gm/IV/BD
DIAGNOSIS:
Chronic pancreatitis with Right retroperitoneal fluid collection along right iliopsoas.
Known case of HTN and Type2 DM
20/07/2021
VITALS
PR-108bpm
BP-130/90mmhg
SPO2-98% @ room temperature
TEMPERATURE-103°F
SYSTEMIC EXAMINATION
CVS:
S1,S2 present ;No murmurs
RESPIRATORY SYSTEM:
BAE present
PER ABDOMEN:
Diffuse tenderness present
Bowel Sounds present
INVESTIGATIONS:
SERUM ELECTROLYTE (in mEq/L)
normal range
Na+:136mEq/L 136-145
K+:3.7mEq/L 3.5-5.1
Cl :90mEq/L 98-107
LIVER FUNCTION TEST:
normal range
TB:8.5mg/dl 0.2-1mg/dl
DB:6.15mg/dl 0.1-0.4mg/dl
ALT(SGPT):26IU/L 10-40IU/L
AST(SGOT):35IU/L 15-40IU/L
ALP:960IU/L 40-125IU/L
TP:4.9g/dl 6-8g/dl
A:2.2 g/dl 3.5-5g/dl
G:2.68g/dl 1.8-3.6g/dl
A/G ratio:0.82 1.7-2.2
TREATMENT:
1) Monitor Vitals
2) Strict I/O charting
3)IVF- 20 NS and 10RL( continous infusion @100ml/hour) with 1 ampoule OPTINEURON
4)INJ. MONOCEF 1gm/IV/BD
5)INJ. PANTOP 40gm/IV /OD
6)INJ. ZOFER 4mg /IV /SOS
7)INJ.TRAMADOL 1ampoule in 100ml NS/IV/SOS
8)INJ.THIAMINE 1 ampoule in 100ml NS/IV/TID
9) TAB SPOROLAC DS/PO/TID (1-1-1)
10)GRBS Charting 8th hourly
11)Temperature charting 4th hourly-Tepid Sponging
12)TAB DOLO 650mg PO/SOS
21/07/2021
VITALS:
PR-98bpm
BP-110/80mmhg
TEMPERATURE -99.2°F
RESPIRATORY RATE -22breaths/min
GRBS-55mg/dl
SYSTEMIC EXAMINATION:
CVS:
S1,S2 present ;No murmurs
RESPIRATORY SYSTEM:
BAE present ; clear
PER ABDOMEN:
Diffuse tenderness present
Bowel sounds present
INVESTIGATIONS:
SERUM CREATININE: 1.3mg/dl
Normal creatinine range: 0.9-1.3 mg/dl
SERUM ELECTROLYTE:
Sodium: 131mEq/L
Potassium:3.6mEq/L
Chloride:88mEq/L
normal range (in mEq/L)
Na+:136-145mEq/L
K+:3.5-5.1mEq/L
Cl:98-107mEq/L
TREATMENT:
1) IVF- 20NS, 10RL, 10DNS given @ pf 100ml/hour with 1 ampoule of OPTINEURON.
2)INJ.MONOCEF 1gm/IV/BD
3)INJ.PAN 40mg/IV/OD
4)INJ.ZOFER 4mg/IV/BD
5)INJ.TRAMADOL 1ampoule in 100ml NS/IV/BD
6)INJ.THIAMINE 1ampoule in 100ml NS/IV/TID
7)TAB CREON PLUS 10,000 IV/PO/TID
8)GRBS Charting 8th hourly
9) Temperature charting 4th hourly
10) TAB DOLO 650 mg PO/SOS
Observations:
The patient is Afebrile
Pain subsided by 50%
No fever spikes
Diagnosis:
Chronic pancreatitis with Rt retroperitoneal fluid collection .
The patient is also diagnosed with Obstructive Jaundice.
22/07/2021
The patient is referred to higher center for ERCP(Endoscopic Retrograde CholangioPancreatography)
DISCHARGE SUMMARY
Discharge Date:21/06/2021
Name of Treating Faculty
DR PALLAVI (INTERNEE)
DR KUSUMA (INTERNEE)
DR SIDDHARTH (INTERNEE)
DR SAMEERA (INTERNEE)
DR CV SIDDHARTH (INTERNEE)
DR VINAY {PGY1}
DR AASHITHA {PGY2}
DR USHA {PGY2}
DR ARJUN [ASSISTANT PROFESSOR]
DR RAKESH BISWAS [HOD]
Diagnosis:
Chronic Pancreatitis with Right Retroperitoneal fluid collection
Obstructive Jaundice
Case History and Clinical Findings
45 year old man, coolie by occupation presented to the casualty with the
Complaints of
Pain in Abdomen since the past 20 days
Loss of Appetite since 20 days
Loose stool since yesterday
History of Presenting Illness
Patient was apparently asymptomatic 5 years back. Then he had similar complaints and was diagnosed with Pancreatitis for which he received treatment for 1 week.
3 years back, on routine investigations , he was diagnosed to be hypertensive and diabetic but ha been on irregular treatment.
Since the past 20 days, he has been experiencing pain in the Epigastric region, radiating to his Right Lower back, aggravated on food intake not associated with vomiting , nausea.
He was taken to a Local hospital outside, where in he was diagnosed with Acute on Chronic pancreatitis, UTI with CUE showing 10-15 pus cells, creatinine 2mg/dl along with a low platelet count of 28,000 cell/cu mm. for which he was admitted in an outside hospital for 4 days and received medications.
He has been consuming 90ml of whiskey, thrice a week since past 20 years. Since the last 1 year, he has been consuming 180ml of whiskey everyday. Last intake was 20 days back.
Past history
Not a known case of TB, Asthma, Epilepsy, CAD, CVA and Thyroid disorders.
Personal history:
Diet: Mixed
Appetite: decreased
Sleep: not adequate
Bowel and bladder habits: regular
Addictions: he has been consuming 90ml of whiskey, thrice a week since the past 20 years. Since the last 1 year, he has been consuming 180ml of whiskey everyday. Last intake was 20 days back
General Examination
Patient is conscious, coherent and cooperative.
On presentation to us, He was a thin built man.
His PR was 100bpm
BP-100/70 mmhg
RR-22cpm
SpO2-98%@room temperature
TEMPERATURE-Afebrile
Icterus present
No pallor, cyanosis, clubbing, koilonychia, generalized lymphadenopathy, edema.
Systemic examination
CNS:
•Speech is normal
•No signs of meningeal irritation
•Motor and Sensory system :Normal
•Cranial nerves :Intact
•Reflexes present
CVS:
•S1, S2 are heard
No murmurs ;No thrills
RESPIRATORY SYSTEM:
•Trachea-central
•BAE- present
•NVBS heard
Inspiratory crepts in Bilateral ISA
PER ABDOMEN:
•Diffuse tenderness present
•Mass palpable present in periumbilical region, right lumbar region
•Bowel sounds heard
Treatment
Day-1
C/o pain in abdomen, lose of appetite, loose stools
1. IVF - 1NS, 1RL @ 125ml/hr
2. INJ. TRAMADOL 1amp in 100ml NS IV/SOS
3. INJ. PAN 40 mg IV/OD
4. INJ. THIAMINE 1 amp in 100ml NS IV/TID
5. TAB. SPOROLAC DS/ PO/TID
Day-2
C/o fever
Same treatment followed
(IVF -2NS, 1RL-continous infusion @ 100ml/hr with 1 amp of Optineuron)
INJ. MONOCEF 1gm/IV/BD
INJ. ZOFER 4mg /IV /SOS
TAB DOLO 650mg PO/SOS
Day-3
C/o fever
Same treatment followed except SPOROLAC-DS
(IVF-1DNS added )
TAB CREON PLUS 10,000 IU/PO/TID added
Investigations
Advice at discharge
referring him to higher centre for ECRP
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