A 40 year old male patient e log

30th June,2021

A 40 YEAR OLD MALE PATIENT WITH  ABDOMINAL PAIN  & VOMITINGS 

6
This E-log has been created under the guidance of DR. Siddharth

Date of admission : 28th June 2021 

This is a case of a -40 year-old gentleman  who is a mechanic and a resident in Nalgonda presented to the OP at 8:30pm with

Cheif complaints of  :
*c/o abdominal pain (squeezing type, non progressive, aggravating) — since morning 
*c/o vomitings (5-6 episodes) — at evening 5pm
       Patient was apparently asymptomatic 3years back, He came to KIMS with c/o abdominal pain and vomitings .
      Then he was diagnosed as Acute pancreatitis and stayed for 1week in the hospital .
      In January patient had similar complaints of abdominal pain, vomitings &constipation. 
      1year ago back pain, abdominal pain (prickling type in epigastric pain) .

History of present illness :
* Non radiating abdominal pain, relieved on forward bending 
*H/O—vomiting non projectile with food particles - 10 episodes 
*CT SCAN REVEALS - interstitial edematous pancreatitis  
*Mild ascites 
*CVS, CNS, RS - normal 
*No E/O necrosis
         Again in January, the patient came with c/o abdominal pain in umbilical region radiating to back — for 2 days 

History of past illness :
*Patient was diagnosed as Acute on chronic pancreatitis secondary to alcohol 
*c/o decrease in urine output 
*No c/o - chest pain, palpitations, sycopal attacks 
*No c/o - shortness of breath, orthopnea & Paroxysmal nocturnal dyspnea
*No c/o - diabetes, tuberculosis, bronchial asthma, HTN and epilepsy. 

Treatment History :
Diabetes  - Not present
Hypertension  - Not present 
CAD - Not present 
Asthma - Not present
Tuberculosis - Not present 
Antibiotics - None used
Hormones - None used
Chemo/Radiation - Not given 
Blood Transfusion- Not given 
Surgeries - None
Other - None
Personal History :
Marital Status- Single 
Occupation - Unemployed, stays at home
Appetite - Normal
Non vegetarian 
Bowels - Regular (non passing flatus i.e, today morning )
Micturition - Normal 
Known allergies - None
Habits/addictions : 
*alcohol (180-360ml/day)- since 7 years fast binge yesterday 
*tobacco (smoking) -since 7 years 
Family History :
Diabetes- No
Hypertension - No
Heart diseases - No
Stroke - No
Cancers - No
Tuberculosis  - No

Physical Examination :

Ll. General 

Pallor - No
Icterus - No
Cyanosis - No
Clubbing of fingers/toes - No
Lymphadenopathy - No
Oedema of feet - No
Malnutrition - No
Temperature -98.9 F
Pulse Rate = 100 beats/min
Respiration (count for a full min)Rate =24 breaths/ min.
BP Lt. Arm = 150/90 mm/Hg.
SPO2 at Room air 98%
GRBS 124 mg%

B. Cardio Vascular System

No Thrills 
Sounds - S1, S2  heard 
No murmurs

C. Respiratory System

No dyspnea
No wheeze
Position of trachea - Central
Breath sounds - Vesicular

D. Abdomen :
Shape - scaphoid
tenderness - present (epigastric region)
No palpable mass
Hernial orifices - Normal
No free fluid
No bruits
Liver - not palpable
Spleen - not palpable
Bowel sounds - Present

E. CNS

Patient is conscious, coherent

Response to speech

No neck stiffness 

No kerning's sign 


Investigations :

1)VITALS RECORD & GRBS LEVELS  :


2) HEMOGRAM :

3)RENAL FUNCTION TESTS:
4) LIVER FUNCTION TEST :

5) SERUM LIPASE :


6) SERUM AMYLASE :

7) HIV 1/2 RAPID TEST :


8) HBs Ag RAPID 


9) ANTIHCV ANTIBODIES —RAPID :



10) ULTRASOUND

11) ECG 
Treatment :
Day1:

1)IVF— NS, RL, DNS
2)NMB till further order 
3)Inj.tramadol 1amp - (50mg in 100ml)—NS/IV/TID
4)Inj.zofer (4mg) —IV/TID
5)Inj.PanD (40mg) — IV/OD
6)BP,PR,RR,temperature monitoring —4th hourly 
7)abdominal girth monitoring —4th hourly 
8)GRBS—6th hourly monitoring (8am-2pm-8pm-2am) 

Day:2

1)Inj.tramadol 1amp - (50mg in 100ml)—NS/IV/TID
2)Inj.zofer (4mg) —IV/TID
3)Inj.PanD (40mg) — IV/OD
@2pm GRBS —104mg/dl


Day3:

1)Inj.tramadol 1amp - (50mg in 100ml)—NS/IV/TID
2)Inj.PanD (40mg) — IV/OD
3)IVF— NS, RL, DNS

Day 4:
1)Inj.tramadol 1amp - (50mg in 100ml)—NS/IV/TID
2)Inj.PanD (40mg) — IV/OD
3)IVF— NS, RL, DNS

Day5:
1)Inj.tramadol 1amp - (50mg in 100ml)—NS/IV/TID
2)Inj.PanD (40mg) — IV/OD
3)IVF— NS, RL, DN

Day 6 : 
1)Inj.tramadol 1amp - (50mg in 100ml)—NS/IV/TID
2)Inj.PanD (40mg) — IV/OD
3)IVF— NS, RL, DN


Date of discharge : 3rd July,2021

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