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Sahil ,Roll no 143

July 24 2022

A CASE OF 50 YR OLD MALE WITH CHRONIC PANCREATITIS WITH ACUTE GASTRITIS

 A 50 YR OLD MALE CAME TO OPD WITH

 C/O PAIN ABDOMEN AND NAUSEA SINCE 4 DAYS .

 PATIENT WAS APPARENTLY ASYMPTOMATIC 8 YRS BACK AND THEN HAD COMPLAINTS OF POLYURIA WHEN HE DIAGNOSED AS DM 2 AND 5 YRS BACK HE DAIGNOSED AS HYPERTENSIVE WHEN HE WENT FOR GENERAL CHECKUP FOR HIS DIABETES 

3 YRS BACK , HE HAD PAIN ABDOMEN AFTER INTAKE OF ALCOHOL ,RYLES ASPIRATION , IV FLUIDS GIVEN ? PANCREATITIS .

 1 YR BACK , HE ADMITTED IN OUR HOSPITAL FOR UNCONTROLLED SUGARS WITH FUNDOSCOPY SHOWING NON PROLIFERATIVE DIABETIC RETINOPATHY, 

RIGHT SIDED DIABETIC FOOT ASSOCIATED WITH POST GILLES AMPUTATION ,FOREFOOT AMPUTATION 10 MONTHS BACK . 

ON 20/6/21 C/O PAIN ABDOMEN AFTER ALCOHOL INTAKE AND DIAGNOSED AS ACUTE PANCREATITIS

LAST BINGE 4 DAYS BACK i.e., ON 20/7/21 

ON 21/7/21 PAIN ABDOMEN TREATED SYMPTOMATICALLY BUT PAIN NOT SUBSIDED .

 ON 24/7/21 .HE CAME AGAIN WITH PAIN ABDOMEN , SQUEEZING TYPE , NON RADIATING , GRADUALLY PROGRESSIVE ,INCREASE AFTER FOOD INTAKE.


PAST HISTORY:

K/C/O DM SINCE 8 YRS HTN SINCE 5 YRS

PERSONAL HISTORY :

SLEEP ADEQUATE

DIET-MIXED 

APPETITE -LOST

 BOWEL AND BLADDER MOVEMENTS - REGULAR 

ALCOHOL INTAKE SINCE 20 YRS (DAILY INTAKE OF 90-180ML/DAY)


FAMILY HISTORY :

NOT SIGNIFICANT

GENERAL EXAMINATION :

PATIENT IS C/C/C

NO SIGNS OF PALLOR,ICTERUS , CYANOSIS,CLUBBING,LYMPHADENOPATHY,PEDAL EDEMA

VITALS:

 TEMP. AFEBRILE

 PULSE 88 BPM

 RR 14 CPM BP 120/70MMHG

 SPO2 98% @ RA 

SYSTEMIC EXAMINATION 

CVS S1 S2 +

\ RS BAE + 

P/A :

SOFT ,TENDERNESS IN EPIGASTRIC AND RIGHT HYPOCHONDRIUM

 CNS NAD

PROVISIONAL DIAGNOSIS:

CHRONIC PANCREATITIS WITH ACUTE GASTRITIS


INVESTIGATIONS:


ECG - NORMAL SINUS RHYTHM

 USG ABD. RAISED ECHOGENECITY OF B/L KIDNEYS CORRELATE WITH RFT



TREATMENT:

 ON 24/7/22

 IVF NS/RL @75ML/HR 

INJ.PANTOP 40MG IV/OD

 INJ.THIAMINE 1 AMP IN 100ML NS IV/TID

 INJ.ZOFER 2CC IV/SOS

 INJ.TRAMADOL 2CC IN 100 ML NS IV/BD

 INJ.HAI S/C 15U - X- 10U

 TAB.ULTRACET 1/2 TAB QID 

TAB.PCM 500MG PO/SOS

BP/PR/TEMP MONITORING 4TH HOURLY

 GRBS 6TH HOURLY 

ON 25/7/22 

IVF NS/RL @75ML/HR 

INJ.PANTOP 40MG IV/OD 

INJ.THIAMINE 1 AMP IN 100ML NS IV/TID 

INJ.ZOFER 2CC IV/SOS

 INJ.TRAMADOL 2CC IN 100 ML NS IV/BD

 INJ.HAI S/C 15U - X- 10U

 TAB.ULTRACET 1/2 TAB QID 

TAB.PCM 500MG PO/SOS 

BP/PR/TEMP MONITORING 4TH HOURLY 

GRBS 6TH HOURLY 

ON 26/7/22

 IVF NS/RL @75ML/HR

 INJ.PANTOP 40MG IV/OD

 INJ.THIAMINE 1 AMP IN 100ML NS IV/TID 

INJ.ZOFER 2CC IV/SOS

 INJ.TRAMADOL 2CC IN 100 ML NS IV/BD 

INJ.HAI S/C 15U - X- 10U

 TAB.ULTRACET 1/2 TAB QID 

TAB.PCM 500MG PO/SOS

 SYP.SUCRALFATE 15 ML PO/TID (15MINS BEFORE FOOD)

 BP/PR/TEMP MONITORING 4TH HOURLY

 GRBS 6TH HOURLY

ON  27/7/22

 IVF NS/RL @75ML/HR 

INJ.PANTOP 40MG IV/OD 

INJ.THIAMINE 1 AMP IN 100ML NS IV/TID 

INJ.ZOFER 2CC IV/SOS

 INJ.TRAMADOL 2CC IN 100 ML NS IV/BD

 INJ.HAI S/C 15U - X- 10U

 TAB.ULTRACET 1/2 TAB QID

 TAB.PCM 500MG PO/SOS

SYP.SUCRALFATE 15 ML PO/TID (15MINS BEFORE FOOD) 

SYP.LACTULOSE 15ML PO/HS

 BP/PR/TEMP MONITORING 4TH HOURLY

 GRBS 6TH HOURLY


DISCHARGE SUMMARY

Name of Treating Faculty

 DR. NUTHNA SRIYA (INTERN)

 DR. SAHIL (INTERN) 

DR. KEERTHI REDDY (INTERN) 

DR. SANGEETHA (INTERN) 

DR. MANASA (PGY1) 

DR. ZAIN ALAM ( PGY2) 

DR. AJITH (PGY2)

 DR. ARJUN KUMAR (AP)

 DR. RAKESH BISWAS (HOD)

 Diagnosis

 CHRONIC PANCREATITIS WITH ACUTE GASTRITIS 

Case History and Clinical Findings

 A 50 YR OLD MALE CAME TO OPD WITH C/O PAIN ABDOMEN AND NAUSEA SINCE 4 DAYS . PATIENT WAS APPARENTLY ASYMPTOMATIC 8 YRS BACK AND THEN HAD COMPLAINTS OF POLYURIA WHEN HE DIAGNOSED AS DM 2 AND 5 YRS BACK HE DAIGNOSED AS HYPERTENSIVE WHEN HE WENT FOR GENERAL CHECKUP FOR HIS DIABETES 3 YRS BACK , HE HAD PAIN ABDOMEN AFTER INTAKE OF ALCOHOL ,RYLES ASPIRATION , IV FLUIDS GIVEN ? PANCREATITIS . 1 YR BACK , HE ADMITTED IN OUR HOSPITAL FOR UNCONTROLLED SUGARS WITH FUNDOSCOPY SHOWING NON PROLIFERATIVE DIABETIC RETINOPATHY, RIGHT SIDED DIABETIC FOOT ASSOCIATED WITH POST GILLES AMPUTATION ,FOREFOOT AMPUTATION 10 MONTHS BACK . ON 20/6/22 C/O PAIN ABDOMEN AFTER ALCOHOL INTAKE AND DIAGNOSED AS ACUTE PANCREATITIS 

LAST BINGE 4 DAYS BACK i.e., ON 20/7/22ON 21/7/22 PAIN ABDOMEN TREATED SYMPTOMATICALLY BUT PAIN NOT SUBSIDED . ON 24/7/22 .HE CAME AGAIN WITH PAIN ABDOMEN , SQUEEZING TYPE , NON RADIATING , GRADUALLY PROGRESSIVE ,INCREASE AFTER FOOD INTAKE. 

K/C/O DM SINCE 8 YRS 

DIET-MIXED APPETITE -LOST BOWEL AND BLADDER MOVEMENTS - REGULAR ALCOHOL INTAKE SINCE 20 YRS (DAILY INTAKE OF 90-180ML/DAY) 

GENERAL EXAMINATION PATIENT IS C/C/C

 TEMP. AFEBRILE

 PULSE 88 BPM 

RR 14 CPM

 BP 120/70MMHG

 SPO2 98% @ RA

 SYSTEMIC EXAMINATION

 CVS S1 S2 + 

RS BAE +

 P/A SOFT ,TENDERNESS IN EPIGASTRIC AND RIGHT HYPOCHONDRIUM

 CNS NAD 

Investigation

 ECG - NORMAL SINUS RHYTHM

 USG ABD. RAISED ECHOGENECITY OF B/L KIDNEYS CORRELATE WITH RFT

 Treatment Given

 ON 24/7/22

 IVF NS/RL @75ML/HR

 INJ.PANTOP 40MG IV/OD

 INJ.THIAMINE 1 AMP IN 100ML NS IV/TID 

INJ.ZOFER 2CC IV/SOS

 INJ.TRAMADOL 2CC IN 100 ML NS IV/BD

 INJ.HAI S/C 15U - X- 10U

 TAB.ULTRACET 1/2 TAB QID

 TAB.PCM 500MG PO/SOS

BP/PR/TEMP MONITORING 4TH HOURLY

 GRBS 6TH HOURLY 

25/7/22

 IVF NS/RL @75ML/HR

 INJ.PANTOP 40MG IV/OD 

INJ.THIAMINE 1 AMP IN 100ML NS IV/TID 

INJ.ZOFER 2CC IV/SOS

 INJ.TRAMADOL 2CC IN 100 ML NS IV/BD

 INJ.HAI S/C 15U - X- 10U 

TAB.ULTRACET 1/2 TAB QID 

TAB.PCM 500MG PO/SOS 

BP/PR/TEMP MONITORING 4TH HOURLY 

GRBS 6TH HOURLY

 26/7/22

 IVF NS/RL @75ML/HR

 INJ.PANTOP 40MG IV/OD 

INJ.THIAMINE 1 AMP IN 100ML NS IV/TID

 INJ.ZOFER 2CC IV/SOS

 INJ.TRAMADOL 2CC IN 100 ML NS IV/BD

 INJ.HAI S/C 15U - X- 10U

 TAB.ULTRACET 1/2 TAB QID 

TAB.PCM 500MG PO/SOS

 SYP.SUCRALFATE 15 ML PO/TID (15MINS BEFORE FOOD)

 BP/PR/TEMP MONITORING 4TH HOURLY 

GRBS 6TH HOURLY

 27/7/22

 IVF NS/RL @75ML/HR 

INJ.PANTOP 40MG IV/OD

 INJ.THIAMINE 1 AMP IN 100ML NS IV/TID

 INJ.ZOFER 2CC IV/SOS

 INJ.TRAMADOL 2CC IN 100 ML NS IV/BD 

INJ.HAI S/C 15U - X- 10U 

TAB.ULTRACET 1/2 TAB QID

 TAB.PCM 500MG PO/SOS 

SYP.SUCRALFATE 15 ML PO/TID (15MINS BEFORE FOOD) 

SYP.LACTULOSE 15ML PO/HS 

BP/PR/TEMP MONITORING 4TH HOURLY 

GRBS 6TH HOURLY

 COURSE IN THE HOSPITAL 

THIS IS A CASE OF 50/M WITH CHRONIC PANCREATITIS WITH ACUTE GASTRITIS .

 THE PATIENT WAS ADMITTED ON 24/7/21 AND WAS TREATED WITH

 IVF NS/RL @75ML/HR 

INJ.PANTOP 40MG IV/OD

 INJ.THIAMINE 1 AMP IN 100ML NS IV/TID

 INJ.ZOFER 2CC IV/SOS

 INJ.TRAMADOL 2CC IN 100 ML NS IV/BD

 INJ.HAI S/C 15U - X- 10U 

TAB.ULTRACET 1/2 TAB QID 

TAB.PCM 500MG PO/SOS 

SYP.SUCRALFATE 15 ML PO/TID (15MINS BEFORE FOOD) 

SYP.LACTULOSE 15ML PO/HS

 BP/PR/TEMP MONITORING 4TH HOURLY

 GRBS 6TH HOURLY

 THE CONDITION OF THE PATIENT AND RECOVERY WAS CLEARLY EXPLAINED TO THE ATTENDANTS AND ADVISED FOR DISCHARGE AND SKED TO CONTINUE THE SAME TREATMENT AT HOME

. Advice at Discharge

 TAB.PANTOP 40 MG PO/OD 

TAB.ULTRACET 1/2 TAB PO/QID 

TAB.PCM 500MG PO/SOS

 TAB.LIVOFEN XL 20MG PO/HS FOR 3 MONTHS 

TAB. GLIMI M2 PO/OD

 SYP.SUCRALFATE 15 ML PO/TID (15MINS BEFORE FOOD) 

SYP.LACTULOSE 15ML PO/HS 

Follow Up

 REVIEW AFTER 15 DAYS TO MEDICINE OP WITH FBS AND PLBS

 

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