30 year old male with epigastric pain
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Case:-
c/o pain over epigastric region since 8:45pm yesterday.
HOPI-
Patient was apparently asymptomatic 1 months back then developed pain over epigastric region, aggravated with spicy food intake and relieved on medication.
Had similar complaints 3 days ago, relieved with medication.
Now patient presented with pain over epigastric region since 8:45 pm, localised over the region, non radiating, tenderness present.
No SOB, palpitations, orthopnea, PND.
No c/o fever, vomitings, diarrhea.
Past history:
Not a k/c/o HTN, DM, thyroid disorders,epilepsy, CVA, asthma.
General examination-
Patient is C/C/C
BP-130/80mmhg
PR- 96 bpm
RR- 18cpm
GRBS- 104 mg/dl
Temp- 98.2F
SYSTEMIC EXAMINATION
CVS- S1S2+,NO MURMURS
RS- BAE+,NVBS HEARD
P/A- SOFT,NON TENDER,BOWEL SOUNDS+
CNS- ORIENTED TO TIME,PLACE AND PERSON
Diagnosis- ?acute pancreatitis
Treatment-
1.NBM till further orders
2.IV NS, RL, DNS at 100ml/ hr
3.Inj. Pan 80mg in 100ml NS IV over 1 hour
4.Monitor vitals 2nd hourly
5.I/O charting
6.GRBS 4th hourly monitoring
CLINICAL IMAGES
Investigations
26/05/2023
01/06/2023
SUMMARY
Diagnosis- ?acute pancreatitis
Complaints-
c/o pain over epigastric region since 8:45pm yesterday.
HOPI-
Pt was apparently asymptomatic 1 months back then developed pain over epigastric region, aggravated with spicy food intake and relieved on medication.
Had similar complaints 3 days ago, relieved with medication.
Now patient presented with pain over epigastric region since 8:45 pm, localised over the region, non radiating, tenderness present.
No SOB, palpitations, orthopnea, PND.
No c/o fever, vomitings, diarrhea.
Past history:
Not a k/c/o HTN, DM, thyroid disorders,epilepsy, CVA, asthma.
General examination-
Patient is C/C/C
BP-130/80mmhg
PR- 96 bpm
RR- 18cpm
GRBS- 104 mg/dl
Temp- 98.2F
SYSTEMIC EXAMINATION
CVS- S1S2+,NO MURMURS
RS- BAE+,NVBS HEARD
P/A- SOFT,NON TENDER,BOWEL SOUNDS+
CNS- ORIENTED TO TIME,PLACE AND PERSON
Treatment-
1.NBM till further orders
2.IV NS, RL, DNS at 100ml/ hr
3.Inj. Pan 80mg in 100ml NS IV over 1 hour
4.Monitor vitals 2nd hourly
5.I/O charting
6.GRBS 4th hourly monitoring
SOAP NOTES
27/05/2023
Ward :ICU
Unit : 5
DOA : 26.5.2023
30 year male with epigastric pain
S
C/O pain abdomen
No fever spikes
Stools passed
O:
Patient is conscious coherent and cooperative
No pallor, icterus ,clubbing,cyanosis,lymphadenopathy ,pedal edema
Vitals :
BP- 130/80 mmhg
PR -82bpm
RR-16cpm
Spo2-95% at room air
Temperature - 98.5F
CVS: s1,s2 heard ,no Murmurs,jvp not raised
RS:BAE,no added sounds ,NVBS,
P/A: soft, distended, tenderness
CNS:NFND
A:
Pain abdomen under evaluation
? Acute gastritis
? Acute pancreatitis
P:
1. NBM till further orders.
2. IVF- NS, RL, DNS at 100ml/hr
3. Inj. Pan 80mg in 100ml NS / IV over 1 hour
4. Monitor vitals 2nd hourly
5. I/O charting
6. GRBS 4th hourly
28/05/2023
Ward :AMC
Unit : 5
DOA : 26.5.2023
30 year male with epigastric pain
S
C/O pain abdomen decreased compared to yesterday
No fever spikes
Stools not passed
O:
Patient is conscious coherent and cooperative
No pallor, icterus , clubbing, cyanosis, lymphadenopathy , pedal edema
Vitals :
BP- 120/70 mmhg
PR -94bpm
RR-16cpm
Spo2-95% at room air
Temperature - 98.7F
I/O:2100/1050ml
GRBS at 8:00am: 113mg/dl
CVS: S1,S2 heard ,no Murmurs, jvp not raised
RS:BAE,no added sounds ,NVBS,
P/A: soft, distended, tenderness present
CNS:NFND
A:
Acute pancreatitis
P:
1. NBM till further orders.
2. IVF- NS, RL, DNS at 100ml/hr
3. Inj. Pan 40mg IV BD
4. Inj. Tramadol 1amp in 100ml NS IV/ BD
5. Inj. Thiamine 200mg in 100 ml NS IV/ TID
6. Monitor vitals 4th hourly
7. I/O charting
8. GRBS 4th hourly
29/05/2023
Ward :ICU
Unit : 5
DOA : 26.5.2023
30 year male with epigastric pain
S
C/O yellowish discolouration of urine
C/O R hypochondriac region pain (tenderness +)
No fever spikes
Stools not passed
O:
Patient is conscious coherent and cooperative
No pallor, icterus ,clubbing,cyanosis,lymphadenopathy ,pedal edema
Vitals :
BP- 120/80 mmhg
PR -96bpm
RR-18cpm
Spo2-95% at room air
Temperature - 98.4F
GRBS at 8:00am 107 mg/dl
CVS: s1,s2 heard ,no Murmurs,jvp not raised
RS:BAE,no added sounds ,NVBS,
P/A: soft, distended, tenderness
CNS:NFND
A:
Acute pancreatitis
P:
1. NBM till further orders.
2. IVF- NS, RL, DNS at 100ml/hr
3. Inj. Pan 40mg IV BD
4. Inj. Tramadol 1amp in 100ml NS IV/ BD
5. Inj. Thiamine 200mg in 100 ml NS IV/ TID
6. Monitor vitals 4th hourly
7. I/O charting
8. GRBS 2nd hourly
30/05/2023
Ward :AMC
Unit : 5
DOA : 26.5.2023
30 year male with epigastric pain
S
C/O yellowish discolouration of urine
C/O epigastric pain
1 fever spike
Stools not passed
O:
Patient is conscious coherent and cooperative
No pallor, icterus , clubbing, cyanosis, lymphadenopathy , pedal edema
Vitals :
BP- 120/80 mmhg
PR -90 bpm
RR-18 cpm
Spo2- 98 %at room air
Temperature - 98.2
GRBS at 8:00am -124mg/dl
CVS: S1,S2 heard ,no Murmurs,
RS:BAE,no added sounds ,NVBS,
P/A: soft, non tender , no organomegaly
CNS:NFND
A:
Acute pancreatitis
P:
1. NBM till further orders.
2. IVF- NS, RL, DNS at 100ml/hr
3. Inj. Pan 40mg IV BD
4. Inj. Tramadol 1amp in 100ml NS IV/ BD
5. Inj. Thiamine 200mg in 100 ml NS IV/ TID
6. Oint. thrombophobe L/A
7.Monitor vitals 2nd hourly
8. I/O charting
9. GRBS 4th hourly
31.5.2023
Ward :AMC
Unit : 5
DOA : 26.5.2023
30 year male with epigastric pain
S
Yellowish coloured urine
Stools not passed
O:
Patient is conscious coherent and cooperative
Icterus present
No pallor, clubbing, cyanosis, lymphadenopathy , pedal edema
Vitals :
BP- 120/80 mmhg
PR -78bpm
RR-16cpm
Spo2-95% at room air
Temperature - 98.2F
GRBS at 8:00am : 98 mg/dl
CVS: s1,s2 heard ,no Murmurs
RS:BAE ,NVBS,
P/A: soft, non tender, no organomegaly
A:
Acute pancreatitis
P:
1. NBM till further orders.
2. IVF- NS, RL, DNS at 100ml/hr
3. Inj. Pan 40mg IV BD
4. Inj. Tramadol 1amp in 100ml NS IV/ BD
5. Inj. Thiamine 200mg in 100 ml NS IV/ TID
6. Monitor vitals 2nd hourly
7. I/O charting
8. GRBS 4th hourly
9. Oint. Thromphobe L/A
01/06/2023
Ward :AMC
Unit : 5
DOA : 26.5.2023
30 year male with epigastric pain
S
No fresh complaints
O:
Patient is conscious coherent and cooperative
Icterus present
No pallor, clubbing, cyanosis, lymphadenopathy , pedal edema
Vitals :
BP- 120/80 mmhg
PR -76bpm
RR-16cpm
Spo2-95% at room air
Temperature -98.2F
CVS: s1,s2 heard ,no Murmurs
RS:BAE ,NVBS,
P/A: soft, non tender, no organomegaly
A:
Acute cholecystitis with cholelithiasis
P:
1. Oral sips allowed- clear fluids if tolerated- coloured fluids.
2. IVF- NS, RL, DNS at 75ml/hr
3. Inj. Pan 40mg IV BD
4. Inj. Tramadol 1amp in 100ml NS IV/ BD
5. Inj. Thiamine 200mg in 100 ml NS IV/ TID
6. Monitor vitals 2nd hourly
7. I/O charting
8. GRBS 4th hourly
9. Oint. Thromphobe L/A
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