SUCHITHA KOLA 65 2019

This is an E-log presentation of Suchitha Kola,Roll No:65 from 3rd Semester,2019 batch which was taken with the help of our interns and pgs, and was taken after proper consent and Communication with the patient.

-A 40year old male who works as a field assistant who is chronic alcoholic came to casualty with 
CHIEF COMPLAINTS:

-abdominal pain since one day & vomitings (10-15 episodes) since one day 

HISTORY OF PRESENT ILLNESS:

 -Patient was apparently asymptomatic 1 day back , since 3 days there h/o binge alcohol consumption (360ml whisky) after which since 1 day he developed pain abdomen which was squeezing type predominantly in epigastric region diffuse type associated with nausea & vomiting 10 to 15 episodes/day. Whenever he consumes water or food he has vomitings - nonbilious, non projectile, water or food as content. 
No h/o loose stools or constipation 
No h/o fever ,shortness of breath, cough
H/o pancreatitis 3 years ago 

PAST HISTORY:

-He is a k/c/o diabetes mellitus since 15 yrs, since 1 yr using HAI 10U in the morning & 5U in the night , before which he was on oral hypoglycemic agents 
He is a k/c/o hypertension since 10 yrs using T. AMLODIPINE 5mg OD 

O/E : 
Pt is c/c/c 
Vitals : 
Temp: 98.4 f
HR: 100 bpm
RR : 18cpm
BP : 160/80 mm hg
Spo2: 99 @ RA
GRBS : 397 mg/dl 

SYSTEMIC EXAMINATION : 

CVS : S1 S2 + . 
RS : BAE + NVBS + 
PA: diffuse tenderness present, more in left hypochondriac region, epigastric region & left iliac fossa
CNS : NAD 

PROVISIONAL DIAGNOSIS : 
-Acute Pancreatitis with uncontrolled sugars ? diabetic nephropathy


BIOCHEMICAL INVESTIGATIONS:



ULTRASOUND REPORT:





 
TREATMENT : 
IVF : NS , RL @ 100ml/hr 
INJ. ZOFER 4mg IV /BD
INJ.PANTOP 40mg IV/OD
INJ. TRAMADOL 1amp in 100ml NS IV/BD
INJ. PIPTAZ 2.25gm IV /QID 
TAB. AMLONG 10mg PO/OD
GRBS monitoring 
INJ. HUMAN ACTRAPID according to sugars 

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