35 year old male, a chronic alcoholic

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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 35 YR OLD MALE WITH ACUTE ON CHRONIC PANCREATITIS

Chief complaints:

• Pain abdomen since 20 days in left hypochondriac region relieved on sitting 

• Chest pain on left side since 20 days

• H/O vomiting last night,  1 episode

• No h/o fever, loose stools

• No h/o palpitations, SOB 

History of present illness:

• Patient was apparently asymptomatic 20 days back ,  but then developed pain in the abdomen in left hypochondriac region which relieved on sitting position along with left sided chest pain. 

• He has history of vomiting - 1 episode last night

History of past illness:

• He is a k/c/o DM and is on OHA's. 

• Had pancreatitis 2 yrs back

Treatment history:

•  Is under treatment for DM

• Has no treatment history of HTN, CAD, stroke, asthma, TB, antibiotics, hormones, chemotherapy ,  blood transfusions and surgeries

Personal history:

• Pt. is married

• Has normal appetite and follows a mixed diet

• His bowels are regular and micturition is normal. 

• Has no known allergies

• He is alcoholic since 20 yrs and consumes 15 units of alcohol per day. 

Family history:

• Has no family history of DM, HTN, CAD, TB, asthma, and epilepsy 

General examination 

Pt is conscious, coherent and cooperative 

•no pallor, icterus, cyanosis, clubbing , lymphadenopathy and edema 

Vitals :

• Temperature - afebrile

• PR - 98/min

• BP - 120/90 mmHg

• RR - 22/min

• SPO2- 99%

• GRBS - 277mg%

Systemic Examination

A. Cardiovascular system

• S1 and S2 heard

B. Respiratory system

• No dyspnoea and wheeze

• Trachea is central in position

• Breath sounds - vesicular

• BAE +

C. Abdomen

• Shape of abdomen - scaphoid

• soft and tenderness in lt. hypochondriac region

D. Central Nervous system

•  no abnormality detected 

Provisional Diagnosis

   ACUTE ON CHRONIC PANCREATITIS WITH K/C/O DM ( pancreatic - exocrine insufficiency) 

Investigations:

On 14.9.21

On 16.9.21

Treatment:

• IV - NS @ 100ml/hr

• IV - RL @ 100ml/hr

• Inj. PAN 40 mg IV/BD

• Inj. OPTINEURON 1 amp in 100ml NS/IV/OD

• Inj. ZOFER 4mg IV/BD

• Ryles tube insertion with urobag

• Inj. Thiamine 2 ampoules 

• Inj. HAI S/C acc. To GRBS

• NBM till further orders

• BP, PR, SPO2, monitoring 4th hourly

• GRBS monitoring 6th hourly

• Inj. TRAMADOL 1 amp in 100ml in NS /IV/SOS