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