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 

 36 YEARS OLD MALE WITH acute pancreatitis with alcohol dependence

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CASE HISTORY

A  36 YEAR OLD MALE , driver BY OCCUPATION ,CAME TO THE casualty WITH 

CHEIF COMPLAINTS OF -

Complains pain in the epigastric region since three days dragging type 

Complains of belching 2 to 3 times per day 

no complains of nausea and vomiting complaints of decreased appetite 

patient was apparently a symptomatic three days ago then he developed 

complains of epigastric pain which is sudden in onset non-radiating type 

no history of nausea vomiting 

history of decreased appetite 

no history of past surgery 

No history of jaundice previously 

no history of gallstones 

history of epigastric pain six months back 

constipation since 3 days

HISTORY OF PRESENTING ILLNESS -

PATIENT WAS APPARENTLY ASYMPTOMATIC 4 DAYS BACK then she developed fever SUDDEN ONSET associated with chills and rigors and headache (frontal and occipital) c/o sob since 4 days (grade 2 ) vomiting since 2 days back -1 episode food as content dragging sensation in leg since 4 days h/o back pain since 3 days NO SIGNIFICANT PAST HISTORY , AND THEN CAME TO KIMS FOR FURTHER EVALUATION NO H/O LOOSE STOOL 

PAST HISTORY - 

 

NOT A KNOWN CASE OF HTN , DM , EPILEPSY , ASTHMA , TB

No previous surgical history 

no history of gallstones in the past

PERSONAL HISTORY :

DIET - MIXED ,APPETITE -Decrease appetite ,BOWEL MOVEMENT - irREGULAR Since 3 days, BLADDER MOVEMENTS - REGULAR , ADDICTIONS(ALCOHOL AND SMOKING) - 

Alcoholics in seven years takes at least 150 ML 

occasional toddy user also Since six months drinks 180 ML per Day 

no history of smoking or chewing tobacco

 brand used it is (Royal stag or IB )180 ML per Day is in six months

FAMILY HISTORY - 

Not significant

ON EXAMINATION -

PATIENT IS CONCIOUS , COHERENT COOPERATIVE

NO PALLOR , ICTERUS , CLUBBING , CYANOSIS , LYMPHADENOPATHY , EDEMA

VITALS - 

TEMPERATURE - AFEBRILE

PULSE RATE - 97 BPM

BLOOD PRESSURE - 100 /70 MM OF HG 

RESPIRATORY RATE - 22

SPO2 - 98% AT ROOM AIR

SYSTEMIC EXAMINATION - 

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS

CENTRAL NERVOUS SYSTEM : Nad

P/a -

Pain in the epigastric region and 

pain is more in the right iliac and lumbar region

No bruit’s 

negative Cullens sign and grey turners sign

Bowel sounds present 

INVESTIGATION - haemogram,cue ,x-ray errect abdomen and xray chest pa,sr creatinine , electrolyte,lft,

Treatment GIVEN -

1 . Ivf ns and rl and dns @ 50 ML /hr

2. Ink . PANTOP 40 MG Iv/OD

3 .Ink zofer 4 mg IV sos

4. inj tramadol 1 amp in 100 ml na IV BD

5.inj buscopan 22 cc iv/sos

6.tab pcm 650 mg po/tid 

7.grbs 6 th hourly

8 temp and i/o charting

clinical images