Acute pancreatitis

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 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

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


I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

This is a case of 30 year old male,worker in occupation from miryalaguda presented to AMC with severe abdominal epigastric pain.

Patient was apparently asymptomatic 1 week ago,4 days back at night he developed mild dull aching pain sudden in onset ,which he ignored ,on the next day morning the pain was gradually progressive and continuous , and presented with Two bouts of vomitings non projectile and non bilious with food particles , then the pain is radiating backwards and relieves on sitting forward with fullness of abdomen and mild fever , then he was rushed to clinic, there is a history of binge drinking of alcohol the day before the pain started

History of passing flatus

Yesterday afternoon he developed difficulty in breathing

Past history:

No history of similar complaints in the past

No h/o diabetes

No h/o hypertension 

No h/o seizures.

No h/o allergy to drugs

Family history:

No relevant family history

Personal history: 

Diet : mixed

Appetite : decreased

Sleep : inadequate 

Bowel:

Bladder: decreased urine output

Addictions: 90 ml beer from 10 years

Treatment history:


General examination: 

Patient is conscious , coherent and co-operative well oriented with time, place and person

Pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: not present

Kolionychia: absent

Lymphadenopathy: absent

Edema : absent

VITALS

Temperature- afebrile

Pulse rate:

Blood pressure:

Respiratory rate:

SYSTEMIC EXAMINATION

CVS:S1,S2+

RS:BVBS+

Per abdomen: 

On inspection:

Palpation:soft, guarding

Percussion:

Auscultation:

INVESTIGATIONS

Hemogram:

19/10/21

HB-17.8

TLC-10,500        

NEUTROPHILS-89%

EOSINOPHILS-3%

LYMPHOCYTES-6%

MONOCYTES-2%

PCV-50.2

PLT-1.64

20/9/21

HB-18.5

TLC-15,300

NEUTROPHILS-88%

LYMPHOCYTES-7%

PCV-51.7

PLT-1.8





LFT

Total bilirubin-2.18

Direct bilirubin-0.83

AST-62

ALT-28

Alkaline phosphatase-112

Total proteins-5.5

Albumin-2.7

A/G ratio-0.98

ECG :


CUE:

trace amount of albumin

Sugar : nil

PC:3-4

EC-2-3

USG ABDOMEN

GRADE 1 FATTY LIVER

Acute pancreatitis 

Mild fasciitis

Minimal pleural effusion on left side

Liver size-14.2cm

CRP-15.5


Serum lipase -1837

Amylase-1244


Electrolytes:

Creatinine-0.8

Sodium-137

Potassium-4.4

Calcium-98

TREATMENT PLAN: 



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