Friday, 12 March 2021

Med. e-log case 4

41yr old male patient came to casuality 

Chief complaints of  - high coloured urine since 2 years

 pain abdomen since 1 week

patient was apparently asymptomatic 2 yrs back and then he developed high coloured urine for which he went to a private hospital  and was told that he had  ureteric calculi(no medical records). Later , he had on and off episodes of high coloured urine weekly twice .He was diagnosed with hypertension in 2019 for which he took medication only for 1 week and then when he went for regular checkup in 2020 again as his BP was high and prescribed medication which he used only for 1 week.
- Pain abdomen since 1 week which was Diffuse, continuous, squeezing type,aggravated on eating food.
 No H/o loose stools and vomitings, No H/o fever .
He had similar episodes in the past and taken treatment for the same 6 months  ago
Past history 
k/C/O HTN since 2Years - not on any medication
Not a k/c/o DM, Epilepsy, Asthma, thyroid disorder 
Cholecystectomy was done 1 year back 
Personal history 
Alcoholic since 7 years[120/ml daily since 1 year]
H/o smoking 10 years back 
Examination - 
pt is conscious coherent cooperative 
No signs of pallor, cyanosis , clubbing ,lymphadenopathy and pedal edema
vitals - 
Temp- Afebrile 
PR-110bpm
BP-180/120mmhg
GRBS-150mg/dl
spo2-98%at RA
Systemic Examination 
CVs-s1,s2 +
RS-BAE+
P/A - 
No visible peristalsis
All quadrants moving equally with respiration
On Palpation 
No local rise of temperature
Tenderness present in the epigastrium , right and left hypochondrium
No rigidity
Guarding present in epigastrium and right hypochondrium

Provisional Diagnosis 
ACUTE PANCREATITIS
Investigations



ON THE DAY OF ADMISSION
Treatment 
1.IVF @100ml/hr
2.INJ PAN 40 MG IV/OD
3 INJ ZOFER 4MG/IV/ OD 
4.INJ OPTINEURON IV/OD
5.INJ TRAMADOL 1 AMP IN 100ml NS/IV/SOS
6.RYLES TUBE INSERTION

DAY 1
1.IVF(NS DNS)@100ML/HR
2.INJ PAN 40 MG IV/OD
3 INJ ZOFER 4MG/IV/ OD 
4.INJ OPTINEURON IV/OD
5.INJ TRAMADOL 1 AMP IN 100ml NS/IV/SOS
6.RYLES TUBE INSERTION

DAY2
1.IVF(NS DNS)@100ML/HR
2.INJ PAN 40 MG IV/OD
3 INJ ZOFER 4MG/IV/ OD 
4.INJ OPTINEURON IV/OD
5.INJ TRAMADOL 1 AMP IN 100ML NS/IV/SOS
6.SYP CREMAFFIN PLUS 15ML/PO/TID

DAY 3
Pain subsided
1)ORAL FLUIDS
2.INJ PAN 40 MG IV/OD
3 INJ ZOFER 4MG/IV/ OD 
4.INJ OPTINEURON IV/OD
5.INJ TRAMADOL 1 AMP IN 100ML NS/IV/SOS
6.SYP CREMAFFIN PLUS 15ML/PO/TID

DAY 4
S-C/o high coloured urine since 2 years
O-On examination 
Bp-160/90mm hg
PR-88bpm
RR-16cpm
CUE- RBC- plenty
         Albumin +++
         Pus cells -plenty
A - acute pancreatitis with urinary tract 
P- TREATMENT GIVEN
1)ORAL FLUIDS
2.INJ PAN 40 MG IV/OD
3 INJ ZOFER 4MG/IV/ OD 
4.INJ OPTINEURON IV/OD
5.INJ TRAMADOL 1 AMP IN 100ML NS/IV/SOS
6.SYP CREMAFFIN PLUS 15ML/PO/TID
7)SYP CITRALKA 15ML PO/BD
8) TAB NITROFURANTOIN 100MG/PO/BD
9)TAB TELMA 40MG /PO/OD

DAY 5
BURNING MICTURITION SLIGHTLY DECREASED AND HEMATURIA PRESENT
acute pancreatitis with urinary tract 
P- TREATMENT GIVEN
1)ORAL FLUIDS
2.INJ PAN 40 MG IV/OD
3 INJ ZOFER 4MG/IV/ OD 
4.INJ OPTINEURON IV/OD
5.INJ TRAMADOL 1 AMP IN 100ML NS/IV/SOS
6.SYP CREMAFFIN PLUS 15ML/PO/TID
7)SYP CITRALKA 15ML PO/BD
8) TAB NITROFURANTOIN 100MG/PO/BD
9)TAB TELMA 40MG/PO/OD


Diagnosis- ACUTE PANCREATITIS (RESOLVED) WITH CHRONIC GLOMERULONEPHRITIS 

 

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