A 27 year old male with fever, abdominal pain and vomitings since 10 days
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Case discussion:
27 year old male came to OPD with chief complaints of fever since 10 days, abdominal pain since 10 days, nausea, vomiting since 10 days
He starts his day at 7 am
who works as a car driver who is an occasional Toddy drinker ( 1 glass of intake for any occasional festival )
History of presenting illness:
Patient was apparently asymptomatic 10 days ago when he attended a function where he consumed 1 litre of Toddy along with red meat , following next day he experienced pain abdomen which was colicky type predominantly in epigastric region diffuse type relieved on bending forward associated with nausea & vomiting 10 to 12 episodes/day. Whenever he consumes water or food he has vomitings - nonbilious, non projectile, water or food as content for 3 days now the frequency reduced to 4 /day
developed Fever low-grade, intermittent, associated with burning micturition and not associated with chills rigors ,cold , cough, generalized weakness ,joint pain
Past history
No similar complaints in the past
Not a case of hypertension, diabetes ,asthma, tb, cad
Personal history
Appetite: decreased
Diet: mixed
Bowel and bladder: regular
Sleep: adequate
No drug or food allergies
Family history
Non contributory
General physician examination
Patient is concious coherent cooperative
Well oriented to time place and person
No pallor
Icterus mild
No cyanosis
No generalized lymphadenopathy
No bilateral pedal edema
Vitals :
Temp: 99.4 f
HR: 100 bpm
RR : 14cpm
BP : 100/70 mm hg
Spo2: 99 @ RA
GRBS : 106 mg/dl
Systemic examination
CVS : S1 S2 + , no murmers
RS : BAE + NVBS +
PA:
Inspection
Shape – scaphoid, not distended
Flanks – free
Umbilicus – Central, inverted
Skin- LSCS scar is present, no sinuses, striae are seen
Dilated veins – absent
Movements of the abdominal wall with respiration is present
No visible gastric peristalsis or intestinal peristalsis
Palpation
superficial:
No local rise of temperature
Local tenderness present
Deep palpation:
No hepatosplenomegaly
Percussion:
Liver dullness at 5th intercoastal space
Auscultation:
Bowel sounds heard
CNS : NAD
Investigation: x ray chest
Diagnosis : Acute Pancreatitis
Treatment:
IVF : NS , RL @ 100ml/hr
INJ. ZOFER 4mg IV /BD
INJ.PANTOP 40mg IV/BD
INJ.PCM 650mg po/TID
INJ.NEOMOL 1g sos(if temp >101 f )
INJ. OPTINEURON 1amp in 100ml NS IV/BD
INJ. TRAMADOL 1amp in 100ml NS IV/BD
Day 3
SOAP NOTES
S: Diffuse Pain abdomen
O:
Temp: 99.4 f
HR: 100 bpm
RR : 18cpm
BP : 120/70 mm hg
Spo2: 99 @ RA
CVS : S1 S2 + .
RS : BAE + NVBS +
PA: diffuse tenderness , severe in epigastric
region
A: ACUTE GASTROENTRITIS
P:
IVF : NS , RL @ 100ml/hr
INJ. ZOFER 4mg IV /BD
INJ.PANTOP 40mg IV/BD
INJ.PCM 650mg po/TID
INJ.NEOMOL 1g sos(if temp >101 f )
INJ. OPTINEURON 1amp in 100ml NS IV/BD
INJ. TRAMADOL 1amp in 100ml NS IV/BD
Day 4
27/2/22
SOAP NOTES
S: Diffuse Pain abdomen, Did not pass stools since 3 days
O:
Temp: 99.4 f
HR: 90 bpm
RR : 19cpm
BP : 110/70 mm hg
Spo2: 99 @ RA
CVS : S1 S2 + .
RS : BAE + NVBS +
PA: diffuse tenderness , severe in epigastric region
A: ACUTE PANCREATITIS
P:
IVF : NS , RL @ 125ml/hr
NBM TILL FURTHER ADVICE
INJ. ZOFER 4mg IV /BD
INJ.PANTOP 40mg IV/BD
INJ.PCM 650mg po/TID
INJ.NEOMOL 1g sos(if temp >101 f )
INJ. TRAMADOL 1amp in 100ml NS IV/BD
INJ. OPTINEURON 1amp in 100ml NS IV/BD
GRBS 12th hrly
Monitor vitals 4th hrly, inform sos
Temp charting 2nd hrly, BP 4th hrly
Start I/O charting
Day 5
28/2/22
SOAP NOTES
S: Diffuse Pain abdomen severe in the epigastric region
O:
Temp: 98.4 f
HR: 90 bpm
RR : 19cpm
BP : 120/80 mm hg
Spo2: 99 @ RA
CVS : S1 S2 + .
RS : BAE + NVBS +
PA: diffuse tenderness , severe in epigastric region
A: ACUTE PANCREATITIS
P:
IVF : NS , RL @ 100ml/hr
INJ. ZOFER 4mg IV /BD
INJ.PANTOP 40mg IV/BD
INJ.PCM 650mg po/TID
INJ.NEOMOL 1g sos(if temp >101 f )
INJ. OPTINEURON 1amp in 100ml NS IV/BD
INJ. TRAMADOL 1amp in 100ml NS IV/BD
Day 6
1/3/22
SOAP NOTES
S: Diffuse Pain abdomen severe in the epigastric region
O:
Temp: 98.4 f
HR: 90 bpm
RR : 19cpm
BP : 120/80 mm hg
Spo2: 99 @ RA
CVS : S1 S2 + .
RS : BAE + NVBS +
PA: diffuse tenderness , severe in epigastric region
A: ACUTE PANCREATITIS
P:
IVF : NS , RL @ 100ml/hr
INJ. ZOFER 4mg IV /BD
INJ.PANTOP 40mg IV/BD
INJ.PCM 650mg po/TID
INJ.NEOMOL 1g sos(if temp >101 f )
INJ. OPTINEURON 1amp in 100ml NS IV/BD
INJ. TRAMADOL 1amp in 100ml NS IV/BD
Day 7
2/3/22
SOAP NOTES
S: Diffuse Pain abdomen(slightly decreased compared to yesterday) severe in the epigastric region
O:
Temp: 98 f
HR: 90 bpm
RR : 18cpm
BP : 120/80 mm hg
Spo2: 99 @ RA
CVS : S1 S2 + .
RS : BAE + NVBS +
PA: diffuse tenderness , severe in epigastric region
A: ACUTE PANCREATITIS
P:
Liquid diet
IVF : NS , RL @ 100ml/hr
INJ. ZOFER 4mg IV /BD
INJ.PANTOP 40mg IV/BD
INJ.PCM 650mg po/TID
INJ.NEOMOL 1g sos(if temp >101 f )
INJ. OPTINEURON 1amp in 100ml NS IV/BD
INJ. TRAMADOL 1amp in 100ml NS IV/BD
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