Acute pancreatitis with alcohol dependency
Acute pancreatitis with alcohol dependency
September 12, 2023
Hi, I am Y.Varunkarthik , 5th semester medical student.
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 patients clinical problems with collective current best evidence based inputs.This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.
I've 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 a diagnosis and treatment plan.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.
Chief Complaint
This is a case of 45 yr old male came to general surgery op with a chief complaints of of pain in abdomen ,fever , vomitings since one day
History of presenting illness
Patient was apparently asymptomatic one day back after which he started developing pain in abdomen which was colicky and non radiating type
H/o of vomitings - 4 episodes till now
Bilious and
non projectile type
H/o fever - low grade ,
No h/o loose stools
No h/o outside food consumption
He had similar complaints in 2018 and had hospital admission
No history of sweating, palpitations.
No history of blood in stools.
History of past illness
Alcohol consumption and have alcohol dependency :
He started consuming alcohol in the form of whisky because of peer pressure .
Consumes alcohol from 16 yrs .
Initially he started consuming 1-2 times / month. Then it gradually increased to 2-4 times/ week after 6 years.
Patient got admitted to hospital 4years back with a complaint of abdominal pain, then the treating doctor suggested to stop consuming alcohol.
Had a break of 2 years of drinking whisky and alcohol and again started drinking in a occasion from past 8months (4-6units/day )
Tobacco consumption ( tobacco chewing):
4 yrs back (1 packet /4days)
Continued drinking and tobacco chewing despite knowing harmful consequences.
N/k/c/o DM , hypertension, epilepsy, tb , thyroid disorders
Family history
Not significant
Personal history:
Diet:mixed
Appetite:lost
Bowel :regular movement
Bladder: normal movements
Addictions: alcohol and tobacco chewing
*Cage assessment:
C- is positive wanted to cut down alcohol
A- positive had anger issues
G- positive felt guilty
E- negative
General examination:
Well oriented to time ,place and person
Moderately built and moderately nourshied
There is no pallor ,cyanosis,lympadenopathy, dehydration, icterus, clubbing of fingers,oedema of feet
Vitals:
Temp:98.7°c
Pulse :88bpm
Respiratory rate:12 cycles/min
Bp:120/80mmHg
Spo2: 97%
Grbs: 135 mg%
Systemic examination
Abdominal examination:
Tenderness positive in epigastric region
Inspection:
Umbilicus shape normal (spherical)
Position - central
No herniation/ discharge
No movements with respiration
Abdomen - fullness and tight abdomen
Skin over abdomen - normal with no pigmentation
Palpation:
Pain above the level of umbilicus
Pain can be perceived every region but most prominent in epigastric region
No engorged veins ,visible pulsations, hernial orifices
Superficial rigidity present
Deep- no case of ascites and fluid thrush
Respiratory examination:
BAE+ ,NVBS +
CVS examination
S1,S2 are heard
No murmurs
CNS examination -NAD
Investigations
ECG
USG FINDINGS
Treatment
1) IV fluids - NS,RL @ 100ml/hour
2)Inj. Tramadol 1 ampoule in 100ml NS i.v/TID
3)Inj.PAN 40 mg I.v/ BD
4) Inj. Zofer 4 mg i.v / TID
5)Inj. Thiamine 100mg/i.v/ TID
