A 56 year old male diagnosed with chronic pancreatitis with uncontrolled sugars

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I have 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 diagnosis and treatment plan.

A 56yr old male came to casualty on 10/08/21 with chief  complaints of pain abdomen since 5 days,polyuria since 5 days, dyspepsia since 2 days 

History of present illness: 

Patient was apparently asymptomatic 5 days back,then he developed pain in the abdomen (Epigastric region) , burning type ,non radiating,not associated with nausea and vomitings.

c/o decreased appetite.

H/o alcohol intake 5 days back and then developed pain abdomen which was diffuse (squeezing type of pain) not associated with nausea and vomitings.He went to a local RMP  and  was diagonsed with Diabetes mellitus (DE NOVO) and was started on TAB GLIBENCLAMIDE and METFORMIN /PO/OD

No H/O burning micturition, fever, cough,cold,SOB,tingling sensation of B/L UL and LL,loose stools and chest pain

Past History :

H/O simliar complaints in the past diagnosed as pancreatitis 

not a K/c/o DM,HTN 

Alcoholic since 30 yrs 

last intake - 3-5 days back

Personal history:

mixed diet

normal appetite

bowel regular 

micturition normal

alcoholic since 30years 

He quit smoking 8yrs back 

General examination :

Patient is conscious, coherent  and cooperative

BP-100/70mmhg

PR-89bpm

Temp-96.5

RR-16cpm

No pallor, cyanosis ,clubbing ,oedema ,generalised lymphadenopathy 

Icterus - present 

Systemic examination:

CVS:

S1S2 heard 

no murmurs and thrills

RS :

NVBS+

BAE+

Per abdomen :

abdomen is soft and non tender 

bowel sounds heard 

Temperature charting 

Clinical images

Investigations 

CUE:

colour: pale yellow

appearance: clear

pH: acidic

CBP :-

Hb: 14.1

TLC: 8,300

Platelets: 1.76

Lymphocytes: 12

Neutrophils: 78

Eosinophils :4

albumin: nil

sugar:++++

PC:2-3

EC: 2-4

RBC:nil

ESR: 35mm/1st hr

LFT-

TB: 7.02

DB: 2.40

AST: 234

ALT: 77

ALP: 876

Total proteins: 6.1

S. Albumin: 2.0

A/G: 0.52

HbA1c:7.4

S electrolytes: 

Na: 138

K: 3.9

Cl: 96

S creatinine: 1.0 mg/dl

S urea: 32mg/dl 

uric acid: 2.0

Serum amylase : 132 IU/L

RBS: 430mg/dl

HbA1c: 7.4

USG: 

-Altered echotexture of pancreas

- increased echogenicity of both kidneys 

- left simple renal cortical cyst 14x17mm in lower pole of left kidney

ECG

Diagnosis: Chronic pancreatitis with uncontrolled sugars(Denovo DM) secondary to pancreatitis .

? Alcoholic gastritis

Treatment given-

Day 1

Inj pan 40 mg IV/BD

INJ Thiamine 2 amp in 500ml NS

INJ HAI ,NPH SC ACC TO GRBS

INJ optineuron 1 amp in 100ml NS IV/BD

Day 2:

Inj pan 40 mg IV/BD

INJ Thiamine 2 amp in 500ml NS

INJ HAI ,NPH SC ACC TO GRBS

INJ optineuron 1 amp in 100ml NS IV/BD

Day 3 

INJ pan 40 mg IV/BD

INJ thiamine 2 amp in 500 ml NS

INJ HAI, NPH SC

INJ optineuron 1 amp in 100 ml NS IV/BD

SOAP NOTES DAY 1

Subjective- 

pain abdomen decreased compared to yesterday 

Objective-

Temp-98 F

PR - 130 bpm 

RR - 18cpm 

BP - 110/80 mm hg 

GRBS - 275 mg/dl

Assessment- 

Chronic pancreatitis with uncontrolled sugars secondary to pancreatitis

Plan of care-

Inj pan 40 mg IV/BD

INJ Thiamine 2 amp in 500ml NS

INJ HAI ,NPH SC ACC TO GRBS

INJ optineuron 1 amp in 100ml NS IV/BD

SOAP NOTES DAY 2

Subjective- 

pain abdomen decreased compared to yesterday 

Objective-

Temp-99 F

PR - 100 bpm 

RR - 18cpm 

BP - 100/70mm hg

GRBS - 175 mg/dl

Assessment- 

Chronic pancreatitis with uncontrolled sugars secondary to pancreatitis

Plan of care-

Inj pan 40 mg IV/BD

INJ Thiamine 2 amp in 500ml NS

INJ HAI ,NPH SC ACC TO GRBS

INJ optineuron 1 amp in 100ml NS IV/BD

 

SOAP NOTES DAY 3

Subjective -

No new complaints 

Objective-

Temp- 98 F

BP - 100/70 mmhg 

PR - 90 bpm 

RR - 18cpm

GRBS - 195 mg/dl

Assessment-

Chronic pancreatitis with uncontrolled sugars secondary to pancreatitis.

Plan of care

- discharge today 

- gasto referral 

-TAB. PAN 40mg/OD

-TAB. MVT /OD

-INJ. HAI- 8-8-8/SC

-INJ. NPH 12-x-10

-watch for hypoglycemic symptoms 

-Home GRBS monitoring

DISCHARGE SUMMARY

Discharge Date : 13/08/21

Ward: ICU

Unit: 2

Name of Treating Faculty- 

DR RAVALI (INTERN) 

DR RAGHU (INTERN) 

DR LAKSHMI MANASA (INTERN) 

DR JANCY( INTERN)

DR ROOPA (INTERN)

DR VAMSI KRISHNA PGY1 

DR RASHMITHA PGY2

DR NIKITHA PGY2

DR HAREEN (SR)

DR ARJUN KUMAR( ASSISTANT PROFESSOR)

DR RAKESH BISWAS (HOD)

Diagnosis :-

CHRONIC PANCREATITIS WITH UNCONTROLLED SUGARS(DENOVO DM) SECONDARY TO PANCREATITIS

Case History and Clinical Findings :-

A 56 YEAR OLD MALE CAME TO CASUALTY WITH CHIEF COMPLAINTS OF PAIN ABDOMEN SINCE 5 DAYS, POLYURIA SINCE 5 DAYS, DYSPEPSIA SINCE 2 DAYS.

HISTORY OF PRESENT ILLNESS-

PATIENT WAS APPARENTLY ASYMPTOMATIC 5 DAYS BACK, THEN HE DEVELOPED PAIN IN THE ABDOMEN(EPIGASTRIC REGION), BURNING TYPE ,NON RADIATING, NOT ASSOCIATED WITH NAUSEA AND VOMITINGS.  C/O DECREASED APPETITE.

H/O ALCOHOL INTAKE 5 DAYS BACK,THEN DEVELOPED PAIN ABDOMEN( SQUEEZING TYPE AND DIFFUSE ) NOT ASSOCIATED WITH NAUSEA AND VOMITINGS. HE WENT TO A LOCAL RMP AND WAS DIAGNOSED WITH DM ( DENOVO). HE WAS STARTED ON TAB. GLIBENCLIMIDE AND METFORMIN /PO/BD

NO H/O BURNING MICTURITION, FEVER, COLD, COUGH, SOB,TINGLING SENSATION OF B/L UL AND LL, LOOSE STOOLS AND CHEST PAIN.

PAST HISTORY -

H/O SIMILAR COMPLAINTS IN THE PAST DIAGNOSED AS PANCREATITIS. NOT A K/C/O DM, HTN

K/C/O ALCOHOLIC SINCE 30 YEARS (LAST INTAKE 3-5 DAYS BACK)

PERSONAL HISTORY -

MIXED DIET

NORMAL APPETITE

BOWEL MOVEMENTS - REGULAR MICTURITION NORMAL

ALCOHOLIC SINCE 30 YEARS

HE QUIT SMOKING 8 YEARS BACK

GENERAL EXAMINATION -

PATIENT IS CONSCIOUS, COHERENT AND COOPERATIVE 

VITALS:

BP- 100/70 MMHG

PR- 89BPM

TEMP- 96.5

RR- 16CPM

NO PALLOR ,CYANOSIS, CLUBBING, EDEMA, GENERALISED LYMPHADENOPATHY 

ICTERUS PRESENT

SYSTEMIC EXAMINATION :

CVS- S1,S2 HEARD. NO MURMURS AND THRILLS

RS - NVBS+, BAE+

PER ABDOMEN- SOFT AND NON TENDER, BOWEL SOUNDS HEARD

CNS - NAD

Investigations 

CUE:

colour: pale yellow

appearance: clear

pH: acidic

CBP :-

Hb: 14.1

TLC: 8,300

Platelets: 1.76

Lymphocytes: 12

Neutrophils: 78

Eosinophils :4

albumin: nil

sugar:++++

PC:2-3

EC: 2-4

RBC:nil

ESR: 35mm/1st hr

LFT-

TB: 7.02

DB: 2.40

AST: 234

ALT: 77

ALP: 876

Total proteins: 6.1

S. Albumin: 2.0

A/G: 0.52

HbA1c:7.4

S electrolytes: 

Na: 138

K: 3.9

Cl: 96

S creatinine: 1.0 mg/dl

S urea: 32mg/dl 

uric acid: 2.0

Serum amylase : 132 IU/L

RBS: 430mg/dl

HbA1c: 7.4

USG -

ALTERED ECHOTEXTURE OF PANCREAS

INCREASED ECHOGENICITY OF BOTH KIDNEYS

LEFT SIMPLE RENAL CORTICAL CYST 14*17MM IN LOWER POLE OF LEFT KIDNEY.

ECG 

Treatment Given(Enter only Generic Name)

1) INJ PAN 40MG IV/BD

2) INJ THIAMINE 2 AMP IN 500 ML NS/IV/TID

3)INJ HAI /NPH PRE MEAL ( 8 AM - 2PM - 8PM)

4) INJ OPTINEURON 1 AMP IN 100 ML NS IV/OD

Advice at discharge -

TAB. PAN 40mg/OD

TAB. MVT /OD

INJ. HAI- 8-8-8/SC

INJ. NPH 12-x-10

WATCH FOR HYPOGLYCEMIC SYMPTOMS

HOME GRBS MONITORING

Follow Up -

REVIEW AFTER 15 DAYS IN MEDICINE OPD WITH FBS/PLBS REPORTS AND PSYCHIATRY OPD I/V/O ALCOHOL DE ADDICTION

When to Obtain Urgent Care

IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.

Preventive Care

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS.

In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: 08682279999 For Treatment Enquiries 

Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language

SIGNATURE OF PATIENT /ATTENDER 

SIGNATURE OF PG/INTERNEE 

SIGNATURE OF ADMINISTRATOR

SIGNATURE OF FACULTY