A 30 year old male with chronic pancreatitis and gastritis

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. 


A 30 year old male ,from Hyderabad,painter by occupation came to casualty with chief complaints of vomitings ,pain in abdomen associated with loose stools since 3 days.

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 4 days back.Then he developed pain in epigastric region,pain was sudden in onset,burning type and aggravated by oily food and alcohol consumption and releived by mentalspas .
He developed vomiting (3-4 episodes per day) which was sudden in onset,non-bilious,non foul smelling and not associated with blood.
Patient also had loose stools(6episodes) which were watery in consistency.
History of alcohol 5days back.
He was admitted with similar complaints 4times earlier in one year.
No history of fever.
N/K/O Hypertension,Diabetes,T.B,Asthma,Thyroid 

PERSONAL HISTORY 
Diet: Mixed
Sleep:adequate 
Appetite:Normal
Micturition:Burning micturition
Bowel movements:regular
Addictions:Alcohol intake

FAMILY HISTORY 

Insignificant 


GENERAL EXAMINATION 

No pallor 
No icterus
No cyanosis
No clubbing 
No lymphadenopathy 
No Edema

VITALS 

Temperature: afebrile 
Blood pressure:120/80mm /Hg
Pulse rate:79bpm
RR:17cpm


CVS
S1 S2 sounds heard 

Respiratory system 
Bilateral air entry present 

Abdomen
Soft,tenderness in epigastrium 
No organomegaly

CNS 
No abnormality detected


INVESTIGATIONS

USG abdomen, ECG, Serum amylase,Electrolytes 

Haemogram:
Hb:14.7gm/dl
TLC :8,200 cells
PCV:40.7
PL:1.5

CUE:
Albumin: nil
PC:2-3
EC:2-3
RBC-nil


Serum lipase-38IU/L
Serum amylase:41IU/L
Serum creatinine:1.1mg/dl
Sodium:147mEq/L
Potassium:3.8mEq/L
Chloride:98mEq/L
Calcium:8.9
Phosphate:2.7
ALP:132
ALT:20
AST:24
TP:5.5
A/G:2.85



Provisional Diagnosis:
Alchoholic gastritis, Pancreatitis 



Treatment:
IVF NS,RL @75ml/hr

Inj PAN 40/iv/BD 

Inj ZOFER 4mg/iv/SOS 

Inj TRAMADOL 1amp in 100 NS /iv/OD 

Inj OPTINEURON 1amp in 100 ml NS/iv/OD

Inj THIAMINE -100 1amp in 100 mlNS/iv/OD 

Monitor vitals 
GRBS 12th hourly








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