A 67 year old male patient with pain abdomen since 4 days
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A 67 year old male Patient came to OPD with chief complaints of pain abdomen since 4 days and at present the pain aggravated
HOPI :
Patient was apparently asymptomatic 4 days back then he developed pain in the abdomen, insidious in onset, gradually progressive dragging type,aggravated on doing work ,after consumption of alcohol ,not associated with nausea,vomitings
No h/o fever,cold,cough
No h/o constipation ,diarrhea
H/o burning micturition
H/o sob grade 2 mmrc
No h/o palpitations,edema, PND, ORTHOPNEA.
Past history
N/k/c/o HTN, Asthma, epilepsy,TB , CAD,CVA
No h/o surgeries in the past
No H/O blood transfusion
No h/o radiation exposure
Personal history: patient is farmer by occupation
Diet mixed
Appetite decreased since 4 days
Sleep adequate
Bowel regular
Micturition not normal
Burning micturition
SLEEP ADEQUATE.
Addictions regularly consumes alcohol about 90 ml/day
Since 30 years .
General physical examination
Pt is conscious coherent cooperative
Moderately built and nourished
Vitals
Bp : 130/80 mm Hg
Pr : 69 bpm
Spo2 98 on RA
Temp: 98.3 F
Grbs 197 mg/dl
No pallor, cyanosis, clubbing, lymphadenopathy,edema
Icterus present
Systemic examination :
Cvs s1 ,s2 heard, no murmurs
CNS no focal neurological deficits noted
Rs BAE + , NVBS
P/A
Inspection : abdomen flat
No scars,sinuses,hernial orifices, pulses,masses,
All quadrants are moving equally with respiration
On palpation:
All inspectory findings are confirmed
Abdomen soft
Tenderness in epigastric and both hypochondriac regions
No local rise of temperature
Guarding+
Rigidity absent
Provisional diagnosis : acute on chronic pancreatitis
INVESTIGATIONS ON 28/11/2023
Final diagnosis :
Chronic pancreatitis
SOAP NOTES: DAY 1
S : c/o pain abdomen
No nausea, vomitings
No fever spikes
O : O/E pt is c/c/c
Temp
PR. 69 bpm
Bp. 120/70 mm hg
Spo2 97 % at RA
GRBS 192 mg/dl
RS BAE + ,NVBS,No added sounds
P/A : Guarding+ , tenderness+ bowel sounds heard
Cvs s1,s2 heard
No murmurs
CNS NFND
A : acute on chronic pancreatitis
P: NBM untill further orders
IVF ns @ 100 ML/hr
Inj ceftriaxone 2 g /IV / BD
INJ METROGYL 500 mg IV /TID
Inj thiamine 200 mg in 100 ML NS IV/tid
Inj Tramadol 100 mg in 100 ML NS IV/BD
INJ PAN 40 Mg IV /OD
INJ ZOFER 4 Mg IV /BD
Day 2
S : c/o pain abdomen reduced
No nausea, vomitings
No fever spikes
O : O/E pt is c/c/c
Temp
PR. 84 bpm
Bp. 110/70 mm hg
Spo2 97 % at RA
GRBS 108 mg/dl
RS BAE + ,NVBS,No added sounds
P/A : Guarding+ , tenderness+ bowel sounds heard
Cvs s1,s2 heard
No murmurs
CNS NFND
A : acute on chronic pancreatitis
P: NBM untill further orders
Inj ceftriaxone 2 g /IV / BD
INJ METROGYL 500 mg IV /TID
Inj thiamine 200 mg in 100 ML NS IV/tid
Inj Tramadol 100 mg in 100 ML NS IV/BD
INJ PAN 40 Mg IV /OD
INJ ZOFER 4 Mg IV /BD
