CHRONIC PANCREATITIS

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan


A 67 years old male came with 

Cheif complaints : stomach pain in right upper quadrant since 3 months 

HOPI: He was apparently asymptomatic 3 months ago then he developed abdominal pain in right lumbar and hypochondriac region which was insidious in onset,gradually progressive,continuous ,not radiating 
Aggregating during cough,eating
Relieving on medication(aceclofenac+ paracetamol)

No h/o  regurgitation
No h/o  nausea
No h/o vomiting
No h/o hematemesis
No h/o fever
No h/o burning micturition

PAST HISTORY :
Not a known case of Diabetes,HTN ,Asthma,epilepsy , CVD, thyroid

FAMILY HISTORY :
Not significant

PERSONAL HISTORY :
Diet:mixed
Appetite:normal 
Sleep: adequate
Bladder and bowel movements: regular
Addictions:
alcohol: since 40 yrs
Cigarette :since 55 yrs  

GENERAL EXAMINATION 
 He was concious /coherent/cooperative
Poorly built and poorly nourished 
Lost 10 kgs in last 3 months 
Ht:162cms 
Wt:45kgs
BMI:17.1kg/mt²

Pallor: +ve
Icterus: -ve
Cynosis: -ve
koilonychia: -ve
Pedal oedema: -ve
Generalised lymphadenopathy: -ve
 
Vitals
BP: 110/70 mm hg
PR: 86 bpm
HR: 62 bpm
RR:16cycles/min 

SYSTEMIC EXAMINATION 
Respiratory system:
Inspection:
Chest - normal shape
Trachea: central in position
Ribs are prominent 
Skin over the chest:no engorged veins ,no scars,no sinuses
Palpation:
All inspiratory findings are confirmed
Temperature normal
Expansion of chest : even 
No tenderness
No scars 
Percussion:
Clavicle, supraclavicular,infraclavicular, supraclavicular,infrascapular,inframammary,mid axillary: resonance heard
Auscultation:
BAE+
NVBS+
No abnormalities

Per abdomen :
Inspection: 
pigmentation on the skin since 2 months 
No swellings
Palpation :
Temperature normal
Soft
Tenderness in the right lumbar and right hypochondriac region
Auscultation:
Dull sounds

CVS: S1,S2 heard ,no murmurs

CNS: no focal neurological deficit 

DIAGNOSIS :
chronic pancreatitis 


INVESTIGATIONS:





Treatment:
1)IV Fluids NS/RL 100ml/hr

2)Inj.TRAMADOL 100mg

3)Tab. ULTRACET 1/2 tab /q.i.d

4)inj.PAN 40mg I.V

5)inj.OPTINEURON 2amp in 100ml NS

6)motitor vitals

7)GRBS ,profile monitoring

8)inj.HAI sc/tid

9)inj.MONOCEF 1gm /i.v/b.d









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