INTERN'S E LOG

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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 patient's clinical problems with collective current best evidence based inputs. 

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome."

CASE

      A 22 years old male patient  who is a student and resident of Itukulapadu came with the chief complaints of pain abdomen and vomittings since 1 day, and did not pass stools today.

HISTORY OF PRESENTAT ILLNESS -

Patient was apparently assymptomatic 1 day back and then developed pain abdomen in the epigastrium, right hypochondrium and umblicus; colicky type. No aggravarting and relieving factors.

Complaints of 1 episode of vomitting yesterday night, watery contains food particles; non - bilious and non - blood tinged.

No h/o loose stools,SOB, pedal edema, chest pain

No h/o decresed urine output

HISTORY OF PAST ILLNESS -

Not a known case of DM, HTN, TB, asthma , epilepsy. No similar complaints In the past. 

PERSONAL HISTORY - 

Appetite - lost

Diet - mixed

Bowel movement - constipation since 1 day

Micturition - normal

Chronic alchoholic since 2 years

No known drug and food allergies

FAMILY HISTORY -

not significant

PHYSICAL EXAMINATION

A) GENERAL EXAMINATION -

Patient is C/C/C 

Pallor - absent 

Icterus - present 

Cyanosis - absent 

Clubbing - absent 

Lymphadenopathy - absent 

Oedema - absent 

Malnutrition - absent 

Dehydration - absent 

PR - 94/ min

BP - 140/80 mmHg

Spo2 - 98%

GRBS - 129 mg %

SYSTEMIC EXAMINATION -

CVS - S1 ,S2 heard . No thrills and murmurs

RS- NVBS , B/L airway present

        Position of trachea - central

ABDOMEN - 

 Shape of abdomen - scaphoid

Tenderness - present  ; epigastrium and right hypochondrium , umblicus and B/ L lumbar areas. Guarding and rigidity - present 

Bowel sounds - absent

CNS - intact

 

PROVISIONAL DIAGNOSIS - 

 Acute Pancreatitis

 

Investigations - 

HCV

LFT 

RFT -

 urea levels : decreased from 27 on 13/6/20  to  on 23 on 16/6/20

creatinine levels : decreased from 0.7 on  13/6/20 to 0.4 on 16/6/20

uric acid levels - increased from 2.5 on 13/6/20 to 3.3   on 16/6/20

Urinec c/s 

blood c/s

Serum amylase - decreased from 335 on 12/6/20  to 52 on 16/6/20

Serum lipase - decreased from 100 on 12/6/20 to 60 on 17/6/20

CBP -

total count was decreased from 15000 on 12/6/20 to 10900 on 18/6/20

Haemogram 

serum electrolytes -

Na : 136 mEq/L

K :  3.8 mEq/L

Cl : 99 mEq/L

ABG -

pH - 7.42

pCO2 - 30.1mmHg

pO2 - 87.1 mmHg

HCO3 - 19.3mmol/L

BEB -  -4.2mmol/l

BEecf - -4.3moml/l

TCO2- 41.9 VOL

O2sat - 96.4%

O2 count - 8.7 vol%

TREATMENT - 

1) IVF  - NS - bolus  -10

               Rl

               DNS

At 125 ml / hr

2) inj pan - 40 /mg/ iv/BD

3)inj zofer - 4mg /IV /TID

4)inj tramadol - 1 amp in 100 ml NS/IV/BD

5) inj thiamine -  1 amp in 100 ml NS/ IV / BD

6) strict 1/0 charting

7)  GRBS - 8th hrly charting

8)inj ceftriaxone - 1g/IV/ BD