45 year old man presented with abdominal pain and loss of appetite.

 45 year old man presented with abdominal pain and loss of appetite.

NOTE

This is an ongoing case and will be updated .
This e log is made under the guidance of Dr. Pallavi.
The reference link (if any) will be mentioned at the bottom.


Date of admission: 20/07/21

Chief complaints:
  • A 45 year old male presented to the casualty with chief complaints of abdominal pain and loss of appetite since the past 20 days and loose stools since yesterday.
  • History of present illness:
  • Patient was apparently asymptomatic 5 years ago when he developed pain in the abdomen and loss of appetite. He was diagnosed with pancreatitis for which he received treatment for 1 week.
  • During routine investigations 3 years ago, he was found to be hypertensive and a diabetic for which he was on irregular treatment.
  • Since the past 20 days, he has been experiencing pain in the epigastric region radiating to his right lower back, which was aggravated on food intake. It was not associated with vomiting or nausea.
  • He was taken to a local hospital where he was diagnosed with acute on chronic pancreatitis. He was also found to have a UTI with CUE results showing:
  • 10-15 pus cells
  • Creatinine: 2mg/dl
  • Platelet count: 28,000 cells/cumm (low)
  • He was admitted in another hospital for 4 days and received medication.

Past history:
Patient is a known case of HTN and type 2 DM since the past 3 years for which he was on irregular treatment.
He is not a known case of CAD, CVA, Epilepsy, TB, Asthma or Thyroid disorders.

Personal history:
  • Occupation: coolie
  • Diet: mixed
  • Appetite: decreased
  • Addictions: consumes alcohol - 90ml of whiskey, thrice a week for the past 20 years. Since the last 1 year, he has been consuming 180ml of whiskey everyday. Last intake was 20 days ago.
  • No known drug allergies.

Family history:
  • No significant family history.

General examination:
  • Patient is conscious, coherent and co-operative.
  • He is thin built.
  • No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy and edema is seen.

Vital signs:
  • PR: 100 bpm
  • BP: 100/70 mmHg
  • SpO2: 98% at RA
  • Temperature: Afebrile

Systemic Examination:
CNS:
  • Speech: normal
  • No signs of meningeal irritation
  • Motor & sensory system: normal
  • Cranial nerves: intact

CVS:
  • S1, S2 were heard
  • No Murmurs
  • No thrills

Respiratory system:
  • Trachea: central
  • BAE: Present
  • Inspiratory crepts in Bilateral ISA.

Per Abdomen:
  • Diffuse tenderness is present 
  • Mass palpable present in periumbilical and right lumbar region.
  • Bowel sounds: heard

Investigations:

ECG
19/07/21
Prolonged QT interval.

Complete urine examination 
19/07/21

Haemogram
19/07/21

2D Echo Report 
19/07/21

Ultrasound Report
19/07/21

Fever chart
Updated: 21/07/21

X Ray scan
19/07/21 

Echocardiograph
20/07/21

Ultrasound
20/07/21

Serum electrolytes (Na, K, Cl)
21/07/21
  •            Electrolyte                  Normal range
  • Sodium: 136 mEq/L                 136-145
  • Potassium: 3.7 mEq/L                3.5-5.1
  • Chloride: 90 mEq/L                     98-107

Liver function test (LFT): 
21/07/21                                   Normal range
  • TB: 8.5 mg/dl                  0.2-1 mg/dl
  • DB: 6.15 mg/dl               0.1-0.4 mg/dl
  • ALT (SGPT): 26 IU/L      10-40 IU/L
  • AST (SGOT): 35 IU/L      15-40 IU/L
  • ALP: 960 IU/L                  40-125 IU/L
  • TP: 4.9 g/dl                        6-8 g/dl
  • Albumin: 2.2 g/dl             3.5-5 g/dl
  • Globulin: 2.68 g/dl           1.8-3.6 g/dl
  • A/G ratio: 0.82                   1.7-2.2

Final Diagnosis: Chronic pancreatitis with Right retroperitoneal fluid collection along right iliopsoas.
Also a known case of HTN and Type 2 DM.

Treatment given:
20/07/21
1. IVF - 20NS, 10RL at 100ml/hr with 1 amp OPTINEURON 
2. Inj. TRAMADOL 1amp in 100ml NS IV/SOS
3. Inj. PANTOP 40 mg IV OD
4. Inj. THIAMINE 1 amp in 100ml NS IV/TID
5. Inj. MONOCEF 1gm/IV/BD
6. Inj. ZOFER 4mg IV/BD
7. Tab. DOLO 650mg PO/SOS

21/07/21
1. IVF - 20NS, 10RL at 100ml/hr with 1 amp OPTINEURON 
2. Inj. TRAMADOL 1amp in 100ml NS IV/SOS
3. Inj. PANTOP 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
7. Inj. ZOFER 4mg IV/BD 
8. Tab CREON 10000 IV/PO/TID
9. Tab. DOLO 650mg PO/SOS 

Patient was also diagnosed with obstructive jaundice 

22/07/21
Patient is referred to higher centre for Endoscopic retrograde cholangiopancreatography (ERCP)

Discharge summary 


Chief complaints:
  • A 45 year old male presented to the casualty with chief complaints of abdominal pain and loss of appetite since the past 20 days and loose stools since yesterday.
  • History of present illness:
  • Patient was apparently asymptomatic 5 years ago when he developed pain in the abdomen and loss of appetite. He was diagnosed with pancreatitis for which he received treatment for 1 week.
  • During routine investigations 3 years ago, he was found to be hypertensive and a diabetic for which he was on irregular treatment.
  • Since the past 20 days, he has been experiencing pain in the epigastric region radiating to his right lower back, which was aggravated on food intake. It was not associated with vomiting or nausea.
  • He was taken to a local hospital where he was diagnosed with acute on chronic pancreatitis. He was also found to have a UTI with CUE results showing:
  • 10-15 pus cells
  • Creatinine: 2mg/dl
  • Platelet count: 28,000 cells/cumm (low)
  • He was admitted in another hospital for 4 days and received medication.

Past history:
Patient is a known case of HTN and type 2 DM since the past 3 years for which he was on irregular treatment.
He is not a known case of CAD, CVA, Epilepsy, TB, Asthma or Thyroid disorders.

Personal history:
  • Occupation: coolie
  • Diet: mixed
  • Appetite: decreased
  • Addictions: consumes alcohol - 90ml of whiskey, thrice a week for the past 20 years. Since the last 1 year, he has been consuming 180ml of whiskey everyday. Last intake was 20 days ago.
  • No known drug allergies.

Family history:
  • No significant family history.

General examination:
  • Patient is conscious, coherent and co-operative.
  • He is thin built.
  • No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy and edema is seen.

Vital signs:
  • PR: 100 bpm
  • BP: 100/70 mmHg
  • SpO2: 98% at RA
  • Temperature: Afebrile

Systemic Examination:
CNS:
  • Speech: normal
  • No signs of meningeal irritation
  • Motor & sensory system: normal
  • Cranial nerves: intact

CVS:
  • S1, S2 were heard
  • No Murmurs
  • No thrills

Respiratory system:
  • Trachea: central
  • BAE: Present
  • Inspiratory crepts in Bilateral ISA.

Per Abdomen:
  • Diffuse tenderness is present 
  • Mass palpable present in periumbilical and right lumbar region.
  • Bowel sounds: heard
Final Diagnosis: Chronic pancreatitis with Right retroperitoneal fluid collection along right iliopsoas.
Also a known case of HTN and Type 2 DM.

Treatment given:
20/07/21
1. IVF - 20NS, 10RL at 100ml/hr with 1 amp OPTINEURON 
2. Inj. TRAMADOL 1amp in 100ml NS IV/SOS
3. Inj. PANTOP 40 mg IV OD
4. Inj. THIAMINE 1 amp in 100ml NS IV/TID
5. Inj. MONOCEF 1gm/IV/BD
6. Inj. ZOFER 4mg IV/BD
7. Tab. DOLO 650mg PO/SOS

21/07/21
1. IVF - 20NS, 10RL at 100ml/hr with 1 amp OPTINEURON 
2. Inj. TRAMADOL 1amp in 100ml NS IV/SOS
3. Inj. PANTOP 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
7. Inj. ZOFER 4mg IV/BD 
8. Tab CREON 10000 IV/PO/TID
9. Tab. DOLO 650mg PO/SOS 

Patient was also diagnosed with obstructive jaundice 

22/07/21
Patient is referred to higher centre for Endoscopic retrograde cholangiopancreatography (ERCP)

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