A 44 Yr male with pain abdomen 6days and fever 6days
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A 44yr old male who is a resident of miryalguda and works as a daily wage labourer came to Casuality with
CHIEF COMPLAINTS:
C/o pain in left lower abdomen since 6 days
C/o Fever since 6days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 6days back then he developed pain abdomen which is insidious in onset,gradually progressive,stabbing in nature,aggravates on coughing.He also has c/o Fever since 6days which is high grade,intermittent in nature,relieved on medication,associated with chills,decreased appetite and vomitings which is bilious,non projectile,non blood tinged,3 episodes per day for 2days.C/o constipation since 2days but passed flatus.
Loss of vision in right eye +
No c/o chest pain,palpitations,SOB,orthopnea,PND
PAST HISTORY:
He has similar complaints in past
1st episode was in 2017 ; during this episode patient had severe pain with vomitings and loose stools for which he admitted in govt hospital and got treated for 3days
2nd episode was in 2022; during this episode he had severe pain but no vomitings and loose stools.He again got admitted in the local hospital and got treated for 2-3 days and they diagnosed as acute pancreatitis.
3rd episode was now i.e,on 05/09/23
He has severe pain in the left lower abdomen with vomitings and fever since 6days
N/K/C/O HTN,DM,CAD,CVA,TB,Asthma,Epilepsy,Thyroid disorders.
FAMILY HISTORY:
No significant family history.
PERSONAL HISTORY:
Diet-mixed
Appetite-decreased
Sleep-regular
Bowel and bladder movements-regular
Addictions:
He is a binge alcoholic.Takes abt 90-120 ml of whiskey everyday.As he works as a daily wage labourer and used to carry around 50kg bags ,due to work stress he drinks alcohol everyday after coming home to get relief from the pain.
No H/o smoking ,toddy intake,drugs
GENERAL AND PHYSICAL EXAMINATION:
Patient is conscious ,coherent,cooperative
Moderately built and nourished
No signs of pallor, icterus,cyanosis,clubbing,pedal edema,
Lymphadenopathy
VITALS:
PR- 86bpm
BP-120/80mmhg
Temperature-afebrile
Spo2-98% at RA
SYSTEMIC EXAMINATION:
CVS examination:
No visible pulsations, scars, engorged veins. No rise in jvp
Apex beat is felt at 5 Intercoastal space medial to mid clavicular line.
S1 S2 heard . No murmurs.
Respiratory system :
Shape of chest is elliptical, b/l symmetrical.
Trachea is central. Expansion of chest is symmetrical
Bilateral Airway Entry - positive
NVBS
Per Abdominal examination:
Soft , tenderness in epigastric and right hypochondrium region
bowel sounds heard
PROVISIONAL DIAGNOSIS:
Acute on chronic pancreatitis
INVESTIGATIONS:
05/09/23
BGT-B +ve
Serology- negative
Hb-9.8
Total count-15,000
Platelet count-4.0
RBS-70mg/dl
Blood urea-18
Uric acid-2.3
S.creatinine-1.2
S.Na+ 136
S.K+ 4.1
S.Cl 99
S.Ca+ 1.12
PT-18sec
INR-1.3
APTT-36sec
TB-1.67
DB-0.45
SGPT-15
SGOT-14
ALP-135
TP-6.0
Alb-3.2
A/G ratio-1.14
S.amylase-210IU/L
S.Lipase-66IU/L
06/09/23
Hb-10.1
Total count-15,000
PCV -30.9
RBC-4.8
Platelet count-4.0
Blood urea-22
Uric acid-2.6
S.creatinine-1.0
S.Na+ 139
S.K+ 4.2
S.Cl 103
S.Ca+ 9.2
07/09/23
Hb-8.9
Total count-11,100
PCV -26.5
RBC-4.1
Platelet count-4.1
PT-19sec
INR-1.4
APTT-39sec
S.amylase-205IU/L
S.Lipase-72IU/L
Hb-9.4
Total count-9,700
PCV -28.3
RBC-4.51
Platelet count-4.30
USG done on 05/09/23:
Liver measuring 13cms with normal structure and echotexture,No F/L,no intrahepatic biliary radicle dilatation
PV-normal
Common bile duct-normal
Gall bladder-distended
Pancreas-head and body visualised
—Head measuring 2.1cm
—body measuring 1.9cm
—main pancreatic duct measuring 3-4mm
Spleen measuring 10cm with normal structure and echotexture
Right kidney measuring 9.5*3cm
Left kidney measuring 9*4cm
Both kidneys show normal structure and echotexture
Aorta,IVC-normal
No ascites,no lymphadenopathy
Prostate shows normal structure and echotexture
IMPRESSION-
Dilated MPD
REVIEW USG I/V/O PANCREATITIS :
—Extensive bowel gas notes
—Pancreas: body visualised ,MPD-6-7mm dilated
Normal structure and echotexture
Mild Peripancreatic collection noted
—suggested S.Amylase,S.lipase levels
—few pockets of collection noted in the inter bowel spaces in left hypochondrium,LIF, RIF
—small bowel loops appear collapsed with sluggish peristalsis.
FEVER CHART:
USG ABDOMEN on 05/09/23:
06/09/23
Date of admission : 05/09/23
Dr.Rakesh Biswas (HOD)
Dr.Sushmitha (SR)
Dr.Kranthi (PGY2)
Dr.Navya (PGY1)
S
Pain in left lower abdomen +
Fever +
O
Patient is conscious/coherent/cooperative
Temp:98.6F
PR: 84bpm, regular
Bp: 120/70 mmhg
SPO2: 98% at RA
CVS: S1 S2+ , no murmurs heard
RS: Bilateral air entry+, NVBS heard
CNS: NFAD
P/A: Tenderness in left lumbar region
A
ACUTE ON CHRONIC PANCREATITIS
P
1)NBM till further orders
2)IV fliuds NS,RL,DNS @75ml/hr
3)Inj Monocef 1gm IV/BD
4)Inj.PAN 40mg IV/OD
5)Inj.Tramadol 1amp in 100ml NS IV/BD
6)Inj.Zofer 4mg IV/SOS
7)Inj.PCM 1gm IV/SOS If temp >101F
8)monitor vitals 2nd hrly
9)Temp 4th hrly
07/09/23
Date of admission : 05/09/23
Dr.Rakesh Biswas (HOD)
Dr.Sushmitha (SR)
Dr.Kranthi (PGY2)
Dr.Navya (PGY1)
S
Pain in the abdomen has been reduced
Fever has been resolved
O
Patient is conscious/coherent/cooperative
Temp:97.9F
PR: 86 bpm, regular
Bp: 120/80 mmhg
GRBS-84mg/dl
SPO2: 98% at RA
CVS: S1 S2+ , no murmurs heard
RS: Bilateral air entry+, NVBS heard
CNS: NFAD
P/A : tenderness present in left lumbar region
A
ACUTE ON CHRONIC PANCREATITIS
P
1)IV fliuds NS,RL,DNS @75ml/hr
2)Inj Monocef 1gm IV/BD
3)Inj.PAN 40mg IV/OD
4)Inj.Tramadol 1amp in 100ml NS IV/BD
5)Inj.Zofer 4mg IV/SOS
6)Inj.PCM 1gm IV/SOS If temp >101F
7)monitor vitals 2nd hrly
8)Temp 4th hrly
08/09/23
Date of admission : 05/09/23
Dr.Rakesh Biswas (HOD)
Dr.Sushmitha (SR)
Dr.Kranthi (PGY2)
Dr.Navya (PGY1)
S
Pain in left lumbar region since morning
O
Patient is conscious/coherent/cooperative
PR: 86bpm, regular
Bp: 110/60 mmhg
SPO2: 98% at RA
CVS: S1 S2+ , no murmurs heard
RS: Bilateral air entry+, NVBS heard
CNS: NFND
P/A: Tenderness present in left lumbar region
A
ACUTE ON CHRONIC PANCREATITIS
P
1)Liquid diet
2)IV fliuds NS,RL,DNS @75ml/hr
3)Inj Monocef 1gm IV/BD
4)Inj.PAN 40mg IV/OD
5)Inj.Tramadol 1amp in 100ml NS IV/sos
6)monitor vitals 2nd hrly
7)Temp 4th hrly
09/09/23
Date of admission : 05/09/23
Dr.Rakesh Biswas (HOD)
Dr.Sushmitha (SR)
Dr.Kranthi (PGY2)
Dr.Navya (PGY1)
S
Pain in left lumbar region since yesterday
O
Patient is conscious/coherent/cooperative
PR: 84bpm, regular
Bp: 100/70 mmhg
SPO2: 98% at RA
CVS: S1 S2+ , no murmurs heard
RS: Bilateral air entry+, NVBS heard
CNS: NFND
P/A: Tenderness present in left lumbar region
A
ACUTE ON CHRONIC PANCREATITIS
P
1)IV fliuds NS,RL,DNS @75ml/hr
2)Inj Monocef 1gm IV/BD
3)Inj.PAN 40mg IV/OD
4)Inj.Tramadol 1amp in 100ml NS IV/sos
6)monitor vitals 4th hrly
7)Inj.Octreotide 100mg SC/TID
8)Inj.Vitamin K 10mg iv/od
9)NBM till further orders
[06/09/23, 8:17:00 PM] Rakesh Biswas Sir: Was he admitted on 22/8?
Check out his case report link from then
Share this link in the 2018 ward group
[06/09/23, 8:31:07 PM] Tejaswini Kandhada: No sir he is not admitted here
[06/09/23, 8:31:16 PM] Tejaswini Kandhada: He went to some gvt hospital
[06/09/23, 8:33:11 PM] Rakesh Biswas Sir: You mean he is not admitted here now or he was not admitted here then but is admitted here now?
[06/09/23, 8:34:20 PM] Tejaswini Kandhada: He was not admitted here then sir
[06/09/23, 8:34:28 PM] Tejaswini Kandhada: Now he is admitted here only
[06/09/23, 9:21:42 PM] ~ Nomika Alli: https://nomikaalli179.blogspot.com/2023/09/50yr-old-chronic-alcoholic-with-acute.html
[06/09/23, 9:54:44 PM] Rakesh Biswas Sir: Thanks. Add this to the description box and share the patient's signed informed consent and contact details with PaJR and case report link by email to informedconsentpajr@gmail.com
[06/09/23, 9:55:23 PM] ~ Nomika Alli: Ok sir
[07/09/23, 9:49:06 AM] Tejaswini Kandhada: 07/09/23
Date of admission : 05/09/23
Dr.Rakesh Biswas (HOD)
Dr.Sushmitha (SR)
Dr.Kranthi (PGY2)
Dr.Navya (PGY1)
S
Pain in the abdomen has been reduced
Fever has been resolved
O
Patient is conscious/coherent/cooperative
Temp:97.9F
PR: 86 bpm, regular
Bp: 120/80 mmhg
GRBS-84mg/dl
SPO2: 98% at RA
CVS: S1 S2+ , no murmurs heard
RS: Bilateral air entry+, NVBS heard
CNS: NFAD
P/A: Soft, no organomegaly, bowel sounds heard
A
ACUTE ON CHRONIC PANCREATITIS
P
1)IV fliuds NS,RL,DNS @75ml/hr
2)Inj Monocef 1gm IV/BD
3)Inj.PAN 40mg IV/OD
4)Inj.Tramadol 1amp in 100ml NS IV/BD
5)Inj.Zofer 4mg IV/SOS
6)Inj.PCM 1gm IV/SOS If temp >101F
7)monitor vitals 2nd hrly
8)Temp 4th hrly
[07/09/23, 1:08:02 PM] Rakesh Biswas Sir: Acute pancreatitis has soft abdomen?
[07/09/23, 2:34:20 PM] Tejaswini Kandhada: No sir
[07/09/23, 3:09:01 PM] Tejaswini Kandhada: Tenderness is present in left iliac region
[07/09/23, 3:14:45 PM] Rakesh Biswas Sir: Left Iliac tenderness can be due to pancreatitis!!?
[07/09/23, 3:16:41 PM] Tejaswini Kandhada: Epigastric and left hypochondriac region
[07/09/23, 3:16:45 PM] Tejaswini Kandhada: Sir
[07/09/23, 3:19:31 PM] Tejaswini Kandhada: But now when i palpate,there is tenderness in left iliac region sir
[07/09/23, 3:24:07 PM] Rakesh Biswas Sir: How would you explain it?
[07/09/23, 4:39:28 PM] Tejaswini Kandhada: Sir now i clearly palpated and the tenderness is in the left lumbar region sir
Which can be the manifestation of acute pancreatitis
[07/09/23, 4:43:57 PM] Rakesh Biswas Sir: Share link to articles with quotes to the relevant portions instead of PDF
[07/09/23, 4:48:24 PM] Tejaswini Kandhada: Left flank pain as the sole manifestation of acute pancreatitis https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726822/pdf/v022p00452.pdf
[08/09/23, 1:17:12 PM] Tejaswini Kandhada: 08/09/23
Date of admission : 05/09/23
Dr.Rakesh Biswas (HOD)
Dr.Sushmitha (SR)
Dr.Kranthi (PGY2)
Dr.Navya (PGY1)
S
Patient complaining of Pain in left lumbar region since morning
O
Patient is conscious/coherent/cooperative
PR: 86bpm, regular
Bp: 110/60 mmhg
SPO2: 98% at RA
CVS: S1 S2+ , no murmurs heard
RS: Bilateral air entry+, NVBS heard
CNS: NFND
P/A: Tenderness present in left lumbar region
A
ACUTE ON CHRONIC PANCREATITIS
P
1)Liquid diet
2)IV fliuds NS,RL,DNS @75ml/hr
3)Inj Monocef 1gm IV/BD
4)Inj.PAN 40mg IV/OD
5)Inj.Tramadol 1amp in 100ml NS IV/sos
6)monitor vitals 2nd hrly
[08/09/23, 7:21:25 PM] Rakesh Biswas Sir: Share the CT images
[09/09/23, 10:10:22 AM] Tejaswini Kandhada: 09/09/23
Date of admission : 05/09/23
Dr.Rakesh Biswas (HOD)
Dr.Sushmitha (SR)
Dr.Kranthi (PGY2)
Dr.Navya (PGY1)
S
Pain in left lumbar region since yesterday
O
Patient is conscious/coherent/cooperative
PR: 84bpm, regular
Bp: 100/70 mmhg
SPO2: 98% at RA
CVS: S1 S2+ , no murmurs heard
RS: Bilateral air entry+, NVBS heard
CNS: NFND
P/A: Tenderness present in left lumbar region
A
ACUTE ON CHRONIC PANCREATITIS
P
1)IV fliuds NS,RL,DNS @75ml/hr
2)Inj Monocef 1gm IV/BD
3)Inj.PAN 40mg IV/OD
4)Inj.Tramadol 1amp in 100ml NS IV/sos
6)monitor vitals 4th hrly
7)Inj.Octreotide 100mg SC/TID
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