30 yr male pt with c/o abdominal pain

CC:
30 yr male pt came to casualty with c/o abdominal pain since 15 days.
Pt was apparently asymptomatic 15 days back, then developed c/o pain abdomen which was insidious in onset, gradually progressive, squeezing type of pain, aggravated upon palpation and consumption of food and fluids, no apparent releving factors. Pain is more prominent in Epigastric and Left lumbar region.
 passing stools and last passed stools today afternoon.
No c/o Nausea/vomitting/loose stools.
 having similar c/o episodes and abdominal pain for every 6months/1 year over last 6 years. Relieved with pain medication 2 days back. Pt went to local hospital when he was treated with analgesics and antibiotics incidentally outside
USG abdomen showing chronic pancreatitis with small intraparenchymal pseudo pancreatic cyst. No pt has been referred to own hospital for further management.
No h/o chest pain, palpitations, syncopal attacks.
Not a k/c/o  HTN/DM/TB/Epilepsy/CVA/CAD.
10yrs back pt started drinking alcohol with friends occasionally which gradually turned into a habit since  then pt used to consume 90-180 mL/day x 7 days a week for approximately for 6-7yrs till 20 days back.

Vitals @ admission:
Temp: 98.6F
BP:130/60 mmHg
HR:80 bpm
RR: 18 cpm
GRBS: 123 mg/dL
SpO2: 98% on RA

General Examination:
Pt is c/c/c
No Pallor/Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
Thyroid normal

Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: NVBS, BAE+
CNS: NAD
P/A: Pain abdomen in Epigastrium and Left Lumbar

Investigations and Reports
05/05/2022:


06/05/2022:
09/05/2022:

Provisional Diagnosis:
Acute on Chronic Pancreatitis

Treatment Given:
1)NBM till further orders
2)Iv fluids- NS,RLand DNS
3)Inj. TRAMADOL 50mg in 100 mL NS
4) Inj. PAN 40mg IV/OD
5)Inj. ZOFER 4mg IV/SOS
6) Inj. THIAMINE 1Amp in 100mL NS/ IV/BD

SOAP NOTES:
DAY1:
SOAP NOTES- AMC- BED 1- DAY 1
DOA: 05/05/2022

S:
Pt c/o pain abdomen- Epigastric and Left lumbar region
O:
Vitals:
Temp: 98.6F
BP:120/90 mmHg
HR:86 bpm
RR: 18 cpm
GRBS: 119 mg/dL
SpO2: 98% on RA

General Examination:
Pt is c/c/c
No Pallor/Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
Thyroid normal

Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: NVBS, BAE+
CNS: NAD
P/A: Pain abdomen in Epigastrium and Left Lumbar

A:
Acute on Chronic Pancreatitis
P:
1)NBM till further orders
2)Iv fluids- NS,RLand DNS
3)Inj. TRAMADOL 50mg in 100 mL NS
4) Inj. PAN 40mg IV/OD
5)Inj. ZOFER 4mg IV/SOS
6) Inj. THIAMINE 1Amp in 100mL NS/ IV/BD

DAY 2:
SOAP NOTES- AMC- BED 1- DAY 2
DOA: 05/05/2022

S:
C/o pain abdomen
Mild tenderness in epigastrium region
No fever spikes
Not passing stools
Flatus +
O:
Vitals:
Temp: 98.6F
BP:130/80 mmHg
HR:74 bpm
RR: 18 cpm
GRBS: 133 mg/dL
SpO2: 98% on RA

General Examination:
Pt is c/c/c
No Pallor/Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
Thyroid normal

Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: NVBS, BAE+
CNS: NAD
P/A: Pain abdomen in Epigastrium and Left Lumbar

A:
Acute on Chronic Pancreatitis
P:
1)NBM till further orders
2)Iv fluids- NS,RLand DNS
3)Inj. TRAMADOL 50mg in 100 mL NS
4) Inj. PAN 40mg IV/OD
5)Inj. ZOFER 4mg IV/SOS
6) Inj. THIAMINE 1Amp in 100mL NS/ IV/BD
7) Tab CREON 10000U PO/TID
8)Abdominal girth monitoring
9)PCV, BUN charting 24th hrly
10) Strict I/O charting

DAY 3:
SOAP NOTES- AMC- BED 1 day 3
DOA: 05/05/2022

S:
- c/o pain abdomen
- mild tenderness in epigastrium
- no fever spikes
O:
Vitals:
Temp: 98.1F
BP:130/80 mmHg
HR:75 bpm
RR: 20 cpm
GRBS: 116 mg/dL
SpO2: 98% on RA

General Examination:
Pt is c/c/c
No Pallor/Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
Thyroid normal

Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: NVBS, BAE+
CNS: NAD
P/A: soft, bowel sounds +
Tenderness in epigastrium 

A:
Acute on Chronic Pancreatitis
P:
1)NBM till further orders
2)Iv fluids- NS,RLand DNS @ 100ml/hr
3)Inj. TRAMADOL 50mg in 100 mL NS IV TID
4) Inj. PAN 40mg IV/OD
5)Inj. ZOFER 4mg IV/SOS
6) Inj. THIAMINE 1Amp in 100mL NS/ IV/BD
7)Tab. CREON 1000U PO TID

DAY 4:
SOAP NOTES- AMC- BED 1 day 4
DOA: 05/05/2022

S:
- c/o pain abdomen
- mild tenderness in epigastrium
- no fever spikes
O:
Vitals:
Temp: 98.1F
BP:130/70 mmHg
HR:86 bpm
RR: 18 cpm
GRBS: 96 mg/dL
SpO2: 98% on RA

General Examination:
Pt is c/c/c
No Pallor/Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
Thyroid normal

Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: NVBS, BAE+
CNS: NAD
P/A: soft, bowel sounds +
Tenderness in epigastrium 

A:
Acute on Chronic Pancreatitis
P:
1)NBM till further orders
2)Iv fluids- NS,RLand DNS @ 100ml/hr
3)Inj. TRAMADOL 50mg in 100 mL NS IV TID
4) Inj. PAN 40mg IV/OD
5)Inj. ZOFER 4mg IV/SOS
6) Inj. THIAMINE 1Amp in 100mL NS/ IV/BD
7)Tab. CREON 10000U PO TID

DAY 5:
SOAP NOTES- AMC- BED 1 day 5
DOA: 05/05/2022

S:
- c/o pain abdomen after 10 min of consuming liquids
- mild tenderness in epigastrium
- no fever spikes
O:
Vitals:
Temp: 98.1F
BP:130/80 mmHg
HR:78 bpm
RR: 20 cpm
GRBS: 95 mg/dL
SpO2: 98% on RA
Input: 2400 mL
Output: 1750 mL

General Examination:
Pt is c/c/c
No Pallor/Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema
Thyroid normal

Systemic Examination:
CVS: S1S2 heard, No murmurs
RS: NVBS, BAE+
CNS: NAD
P/A: soft, bowel sounds +
Tenderness in epigastrium 

A:
Acute on Chronic Pancreatitis
P:
1)NBM till further orders
2)Iv fluids- NS,RLand DNS @ 100ml/hr
3)Inj. TRAMADOL 50mg in 100 mL NS IV SOS
4) Inj. PAN 40mg IV/OD
5)Inj. ZOFER 4mg IV/SOS
6) Inj. THIAMINE 1Amp in 100mL NS/ IV/OF
7)Tab. CREON 10000U PO TID
8) Inj. OCTROTIDE 100 mcg S/C TID
9) Abdominal girth monitoring
10)PCV, BUN charting 24th hrly
11) Strict I/O charting


Blog Link:
http://anuraag10-2k16.blogspot.com/2022/05/30-yr-male-pt-with-co-abdominal-pain.html

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