CASE HISTORY 1

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



A 47 year old lorry driver  came with c/o pain abdomen since today 3 am (23/2/2022).
HISTORY OF PRESENT ILNESS:
-Patient was apparently  asymptomatic 14 years back, went to hospital for regular check up and was diagnosed with DM -2  and since then he is on OHA’s.
-10 years back on routine check up he came to be diagnosed with hypertension and he is on TELMA - H / OD . 
-20 years back diagnosed with renal calculi ,pain- operated
-4.5 years back , patient c/o abdominal full ness , associated with  tightness , squeezing type , relieved with vomitings  associated with  vomitings  bilious  associated with food particles 
-Patient is having similar episodes every once in  a year
-Patient is chronic alcoholic since 20 -25 years, whiskey ( 90-180 ml) / every day , 4-5 times / week 
-Fever , burning micturition since 5 days 
-Last binge 4-5 days back , 90 ml whiskey 
-No c/o chest pain , palpitations 
HISTORY OF PAST ILNESS-:
-Dm since 14 years and on tab gilmi - m2 
-HTN since 10 years and on tab telma-h /OD -Tb , bronchial asthma , cad, 

SURGICAL HISTORY-:previously had surgery for hernia
PERSONAL HISTORY:
Married 
Lorry driver  by occupation 
Appetite:normal
Bowel bladder movements: regular 
Addictions: alcohol consumption since 20-25 years , whiskey,(90-180 ml)/ every day ,4-5 times / week 
90-180ml ,whiskey per day: 
FAMILY HISTORY:
not significant 

O/e:
Pt is c/c/c,well oriented to time,place,person
No signs of icterus,clubbing,cyanosis,lymphadenopathy,pedal edema.
VITAL-:
Temp:101 F 
Pr:97 bpm 
Rr:17 cpm
Bp:140/100
Grbs:86 mg /dl

SYSTEMIC EXAMINATION-:
Cvs: S1,S2 heard
P/A: rigid, tenderness in epigastric region 

INVESTIGATIONS-:(23/2/2022)

Haemogram:
Hb-15.2
Tlc-10,600
N/L/E/M-87/06/01/06
Pcv -41.5
Plt-1.60
Imp- normocytic normochromic with neutrophilia 

Cue:
Albumin- trace
Sugar- + +
Pus cells- 3-4

Urea - 29
Serum creatinine - 0.9
Sodium -135
Potassium-3.4
Chloride -103

Tb-3.38
Db-1.91
Sgot-328
Sgpt-182
Alkaline phosphate -245
Total proteins-6.4
Albumin-3.9
A/G ratio-1.56

ABG:
Ph- 7.38
PCO2- 23.5
PO2-86.6
HCO3-13.8
 
Serum amylase- 185
Lipase-89
 
Hba1c-6.9 

25/2/22

Tb-3.78
Db-2.82
Sgot-88
Sgpt-101
Alkaline phosphate -225
Total proteins-6.2
Albumin-3.6
A/G ratio-1.41

Haemogram:
Hb-14.7
Tlc-5,100
N/L/E/M-70/18/4/8
Plt-85.4
Imp- normocytic normochromic 


Pt-19
Aptt-38
Inr-1.4
Usg- 
Imp-1)Acute on chronic pancreatitis 
        2)Left renal calculi 

Cect abdomen-
Imp-1)chronic calculus pancreatitis 
        2) Bilateral small renal calculi 
        3)Gall bladder wall edema- reactivePlan:
1.Ivf with ns and rl @ 100 ml/hr 
2.NBM till further order
3.Inj pan 40mg/iv/bd
4.inj zofer 4mg/iv/tid
5.inj tramadol 1amp in 100ml ns /iv/tid
6.tab telma -h /od 
7.inj thiamine 1amp in 100ml ns/iv/tid
8.inj  hai s/c tid acc to sliding scale 
8.strict input output charting 

Diagnosis: Acute  on chronic pancreatitis with Dm since 14 years  and Htn since 10 years

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