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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.
Name :- Kattekola sathwik
Roll no :- 75
Case report
Date of admission :- 1/3/2023
A 27 yr old male hailing from rural nalgonda Has presented with Complaints of Pain abdomen since 2 days Which was insidious in onset and Diffuse , More on left Side. The patient had also c/o vomitings -2 episodes since 2 days , Non bilious, non projectile, No evidence of Blood in Vomitus
History of Burning Mictirition Present Since 3 days
The patient Has habit of Alcohol Consumption - occasionally -
He Reports to have Consumed About 500 ml of whiskey 4 days ago
The patient denies history of Any Loose stools, constipation.
The patient was Hospitalised For similar complaints Last Yr. He was managed Conservatively.
Associated Comorbidities :-
He is a Known Hypertensive Since 2 yrs on Irregular medication (Telma 40)
Past history :-
Not a K/C/O Diabetes, Asthmaz TB, Epilepsy, CAD, CVA
Personal History :-
Appetite is normal, Diet is mixed
Burning Micturition +
Bowel habits regular
Sleep :- adequate in Other days, since 2 days disturbed due to pain
General Physical Examination
The patient is C/C/C
Well oriented to time, place and Person
No pallor icterus,cyanosis, Lymphadenopathy, pedal edema
Vitals
PR:- 86 bpm
RR:- 16 cpm
Temp:- 98F
BP:- 140/90 mmHg
Per Abdomen :-
The abdomen is Vertically oval, Umbilicus is Central in position
No Visible scars Sinuses , Fistulae
On palpation , The Abdomen is soft and Non tender
On Auscultation, Bowel sounds heard.
CVS :- S1 S2 heard
RS :- NVBS heard
CNS :- NFND
Diagnosis :- ACUTE PANCREATITIS
Investigations As of 1/3/23
1. CHEST X RAY PA VIEW
2. ECG
3. 2D ECHO
Review 2D echo 3/3/23
LFT
Serum Amylase
Serum Lipase
Hemogram
USG abdomen
CUE
2/3/2023
Serum creatinine
Blood urea
Hemogram
3/3/23
SERUM POTASSIUM
TREATMENT GIVEN
1. NBM TILL FURTHER ORDERS
2. INJ. PAN 40 MG IV OD
3. INJ. ZOFER IV BD
4. INJ. TRAMADOL 50 MG IN 100 ML NS IV SOS
5. INJ . THIAMINE 200 mg In 100 ML NS IV TID
6. IV FLUIDS AT 75 ML PER HOUR
SOAP Notes
Date :- 2/3/2023
C/S/B
Dr Nikitha (SR) Dr. Vamsi (PGY3) Dr Keerthi Dr.Vivek(PGY1) Dr Prachethan (PGY1) Dr.Sathwik(Intern) Dr. Sofia (Intern)
S
Pain abdomen Reduced
O
Pt is C/C/C
Temp :- 98.5F
PR:- 82 bpm
RR:-15cpm
BP:-110/80 mmHg
GRBS :-91 mg/dL
CVS :-s1s2 present no murmurs
RS:-BAE+NVBS
PA:- Soft
CNS :- HMF intact NFND
A
ACUTE PANCREATITIS SECONDARY TO ALCOHOL WITY HIGHT OUTPUT HEART FAILURE ?WET BERI BERI
P
1. NBM TILL FURTHER ORDERS
2.INJ. TRAMADOL 50 MG IN 100 ML NS IV SOS
3.INJ.PAN 40 MG IV OD
4.INJ ZOFER 4MG IV BD
5. INJ. THIAMINE 200MG IN 100 ML NS
3/3/23
C/S/B
Dr Nikitha (SR) Dr. Vamsi (PGY3) Dr Keerthi Dr.Vivek(PGY1) Dr Prachethan (PGY1) Dr.Sathwik(Intern) Dr. Sofia (Intern) S
Pain abdomen Reduced
O
Pt is C/C/C
Temp :- 98.5F
PR:- 82 bpm
RR:-15cpm
BP:-110/80 mmHg
GRBS :-91 mg/dL
CVS :-s1s2 present no murmurs
RS:-BAE+NVBS
PA:- Soft
CNS :- HMF intact NFND
A
ACUTE PANCREATITIS SECONDARY TO ALCOHOL WITY HIGH OUTPUT HEART FAILURE ?WET BERI BERI
P
1. Oral Fluids
2.INJ. TRAMADOL 50 MG IN 100 ML NS IV SOS
3.INJ.PAN 40 MG IV OD
4.INJ ZOFER 4MG IV BD
5. INJ. THIAMINE 200MG IN 100 ML NS 6.INJ.KCL 1AMP IN 500ML NS OVER 4 HRS 7.TAB.TELMA40MG PO OD
4/5/23
C/S/B
Dr Nikitha (SR) Dr. Vamsi (PGY3) Dr Keerthi Dr.Vivek(PGY1) Dr Prachethan (PGY1) Dr.Sathwik(Intern) Dr. Sofia (Intern) S
Pain abdomen Reduced
O
Pt is C/C/C
Temp :- 98.5F
PR:- 82 bpm
RR:-15cpm
BP:-110/80 mmHg
GRBS :-91 mg/dL
CVS :-s1s2 present no murmurs
RS:-BAE+NVBS
PA:- Soft
CNS :- HMF intact NFND
A
ACUTE PANCREATITIS SECONDARY TO ALCOHOL WITY HIGH OUTPUT HEART FAILURE ?WET BERI BERI
P
1.Soft diet
2.INJ. TRAMADOL 50 MG IN 100 ML NS IV SOS
3.INJ.PAN 40 MG IV OD
4.INJ ZOFER 4MG IV BD
5. INJ. THIAMINE 200MG IN 100 ML NS 6.INJ.KCL 1AMP IN 500ML NS OVER 4 HRS 7.TAB.TELMA40MG PO OD
5/3/23
C/S/B
Dr Nikitha (SR) Dr. Vamsi (PGY3) Dr Keerthi Dr.Vivek(PGY1) Dr Prachethan (PGY1) Dr.Sathwik(Intern) Dr. Sofia (Intern) S
Pain abdomen Reduced
O
Pt is C/C/C
Temp :- 98.5F
PR:- 82 bpm
RR:-15cpm
BP:-110/80 mmHg
GRBS :-91 mg/dL
CVS :-s1s2 present no murmurs
RS:-BAE+NVBS
PA:- Soft
CNS :- HMF intact NFND
A
ACUTE PANCREATITIS SECONDARY TO ALCOHOL WITY HIGH OUTPUT HEART FAILURE ?WET BERI BERI
P
1.Soft diet
2.INJ. TRAMADOL 50 MG IN 100 ML NS IV SOS
3.INJ.PAN 40 MG IV OD
4.INJ ZOFER 4MG IV BD
5. INJ. THIAMINE 200MG IN 100 ML NS 6.INJ.KCL 1AMP IN 500ML NS OVER 4 HRS 7.TAB.TELMA40MG PO OD
6/3/23
Date of admission
1/3/23
Dr Nikitha (SR) Dr. Vamsi (PGY3) Dr Keerthi Dr.Vivek(PGY1) Dr Prachethan (PGY1) Dr.Sathwik(Intern) Dr. Sofia (Intern) S
Pain abdomen Reduced
O
Pt is C/C/C
Temp :- 98.5F
PR:- 82 bpm
RR:-15cpm
BP:-110/80 mmHg
GRBS :-91 mg/dL
CVS :-s1s2 present no murmurs
RS:-BAE+NVBS
PA:- Soft
CNS :- HMF intact NFND
A
ACUTE PANCREATITIS SECONDARY TO ALCOHOL WITY HIGHT OUTPUT HEART FAILURE ?WET BERI BERI
P
1. Plenty of Oral Fluids
2.Tab.THIAMINE 100 MG PO BS
3.TAB.TELMA 40 MG PO OD
4. INJ.TRAMADOL IV SOS
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