45 yr old male patient with reccurent acute pancreatitis and alcohol dependence syndrome

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 AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 

CHIEF COMPLAINTS- 

C/o itchy skin lesion on left foot since 10 yrs which initially started as a papule 
C/o pain in the abdomen since 3 days
C/o constipation since 3days
C/o vomitings since 2days

HISTORY OF PRESENT ILLNESS- 

Pt was apparently asymptotic 2days ago then he developed pain in the abdomen-epigastric region. Pain is sudden in onset, gradually progressive. Pain increases more after eating food and on lying in supine position. Pain is relieved on sitting position and on bending forward.
 H/o 3 episodes of vomiting yesterday after eating food. Content- food, non bilious, non projectile, not blood tinged. Constipation since 3days 
No h/o fever , cough , cold, SOB, loose stools, giddiness

HISTORY OF PAST ILLNESS-

Last binge of alcohol consumption 2days ago
H/o similar complaints 2yrs ago diagnosed as acute pancreatitis. 
No H/o diabetes mellitus, hypertension, thyroid disorders,TB,CAD,CVBA, Epilepsy 

TREATMENT HISTORY- 

Application of unknown topical medication on skin lesions .

PERSONAL HISTORY-

Appetite- normal. Non-vegetarian 
Bowel- constipation
Micturition- normal
Addictions-
Alcohol- consumes 2 quarters alcohol/day 
Smoking- nil
No h/o drug abuse

FAMILY HISTORY- 

Father is an alcoholic

PHYSICAL EXAMINATION-

GENERAL EXAMINATION- 

No signs of pallor, icterus, cyanosis, clubbing of fingers, lymphadenopathy, oedema, dehydration

VITALS-

Temperature- 97.8
Pulse rate- 76/min
Respiration rate- 18/ min
BP- 110/80 mm Hg
SPO2- 96%
GRBS- 124mg %

SYSTEMIC EXAMINATION-

CVS-

Thrills- No
Cardiac sounds- s1s2 heard
Cardiac murmurs- No

RESPIRATORY SYSTEM-

Dyspnoea- no
Wheeze- no
Position of trachea- central
Breath sounds- vesicular

ABDOMEN-

Shape of abdomen- scaphoid 
Tenderness- no
Palpable mass - no
Hernial orifices - normal
Free fluid- no
Bruit- no
Liver- not palpable
Spleen- not palpable
Bowel sounds- present sluggish 2mins
CNS- pt is conscious coherent and afebrile on touch 
Level of consciousness- conscious 
Speech- normal
Glasgow scale- E4, U5, M6 

Fever chart


IVESTIGATIONS:
HAEMOGRAM


CUE


2D ECHO


UlTRASOUND

ECG

PROVISIONAL DIAGNOSIS-
Acute pancreatitis 

TREATMENT-
NBM till further order
IV fluids 
Inj. TRAMADOL 1 amp in 100 ml NS in IV  
Inj THIAMINE 1 amp in 200 ml NS IV BD 

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