February 24, 2022
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27 year old male came to OPD with complaints of fever for 5 days, abdominal discomfort since 5 days, nausea, vomiting ,loose stools since 5 days, burning micturition since 3 days.
Patient was apparently asymptomatic 5 days back who works as a car driver since 5 years who was occasional Toddy drinker ( 1 glass of intake for any occasional festival )
5 days ago he went to function where he consumed 1 litre of Toddy along with red meat , following next day he experienced pain abdomen which was squeezing type predominantly in epigastric region diffuse type associated with nausea & vomiting 10 to 12 episodes/day. Whenever he consumes water or food he has vomitings - nonbilious, non projectile, water or food as content for 3 days now the frequency reduced to 4 /day
LOOSE STOOLS - watery, small volume, no blood or mucus in stools
FEVER low-grade, intermittent , associated with burning micturition not associated with chills& rigors cold , cough, weakness ,joint pains
O/E :
Pt is c/c/c
Vitals :
Temp: 99.4 f
HR: 100 bpm
RR : 14cpm
BP : 100/70 mm hg
Spo2: 99 @ RA
GRBS : 106 mg/dl
SYSTEMIC EXAMINATION :
CVS : S1 S2 + .
RS : BAE + NVBS +
PA: mild tenderness in epigastric region
CNS : NAD
DIAGNOSIS : Acute Pancreatitis
TREATMENT :
IVF : NS , RL @ 100ml/hr
INJ. ZOFER 4mg IV /BD
INJ.PANTOP 40mg IV/BD
INJ.PCM 650mg po/TID
INJ.NEOMOL 1g sos(if temp >101 f )
INJ. OPTINEURON 1amp in 100ml NS IV/BD
INJ. TRAMADOL 1amp in 100ml NS IV/BD
Investigations:
AMC BED NO. 1
UNIT -4
Day 3
SOAP NOTES
S: Diffuse Pain abdomen
O:
Temp: 99.4 f
HR: 100 bpm
RR : 18cpm
BP : 120/70 mm hg
Spo2: 99 @ RA
CVS : S1 S2 + .
RS : BAE + NVBS +
PA: diffuse tenderness , severe in epigastric
region
A: ACUTE GASTROENTRITIS
P:
IVF : NS , RL @ 100ml/hr
INJ. ZOFER 4mg IV /BD
INJ.PANTOP 40mg IV/BD
INJ.PCM 650mg po/TID
INJ.NEOMOL 1g sos(if temp >101 f )
INJ. OPTINEURON 1amp in 100ml NS IV/BD
INJ. TRAMADOL 1amp in 100ml NS IV/BD
AMC BED NO. 1
UNIT -4
Day 4
27/2/22
SOAP NOTES
S: Diffuse Pain abdomen, Did not pass stools since 3 days
O:
Temp: 99.4 f
HR: 90 bpm
RR : 19cpm
BP : 110/70 mm hg
Spo2: 99 @ RA
CVS : S1 S2 + .
RS : BAE + NVBS +
PA: diffuse tenderness , severe in epigastric region
A: ACUTE PANCREATITIS
P:
IVF : NS , RL @ 125ml/hr
NBM TILL FURTHER ADVICE
INJ. ZOFER 4mg IV /BD
INJ.PANTOP 40mg IV/BD
INJ.PCM 650mg po/TID
INJ.NEOMOL 1g sos(if temp >101 f )
INJ. TRAMADOL 1amp in 100ml NS IV/BD
INJ. OPTINEURON 1amp in 100ml NS IV/BD
GRBS 12th hrly
Monitor vitals 4th hrly, inform sos
Temp charting 2nd hrly, BP 4th hrly
Start I/O charting
AMC BED 1
UNIT -4
Day 5
28/2/22
SOAP NOTES
S: Diffuse Pain abdomen severe in the epigastric region
O:
Temp: 98.4 f
HR: 90 bpm
RR : 19cpm
BP : 120/80 mm hg
Spo2: 99 @ RA
CVS : S1 S2 + .
RS : BAE + NVBS +
PA: diffuse tenderness , severe in epigastric region
A: ACUTE PANCREATITIS
P:
IVF : NS , RL @ 100ml/hr
INJ. ZOFER 4mg IV /BD
INJ.PANTOP 40mg IV/BD
INJ.PCM 650mg po/TID
INJ.NEOMOL 1g sos(if temp >101 f )
INJ. OPTINEURON 1amp in 100ml NS IV/BD
INJ. TRAMADOL 1amp in 100ml NS IV/BD
Ward Case
UNIT -4
Day 6
1/3/22
SOAP NOTES
S: Diffuse Pain abdomen severe in the epigastric region
O:
Temp: 98.4 f
HR: 90 bpm
RR : 19cpm
BP : 120/80 mm hg
Spo2: 99 @ RA
CVS : S1 S2 + .
RS : BAE + NVBS +
PA: diffuse tenderness , severe in epigastric region
A: ACUTE PANCREATITIS
P:
IVF : NS , RL @ 100ml/hr
INJ. ZOFER 4mg IV /BD
INJ.PANTOP 40mg IV/BD
INJ.PCM 650mg po/TID
INJ.NEOMOL 1g sos(if temp >101 f )
INJ. OPTINEURON 1amp in 100ml NS IV/BD
INJ. TRAMADOL 1amp in 100ml NS IV/BD
Gastroenterologist opinion :
Review 2d echo :
Ward Case
UNIT -4
Day 7
2/3/22
SOAP NOTES
S: Diffuse Pain abdomen(slightly decreased compared to yesterday) severe in the epigastric region
O:
Temp: 98 f
HR: 90 bpm
RR : 18cpm
BP : 120/80 mm hg
Spo2: 99 @ RA
CVS : S1 S2 + .
RS : BAE + NVBS +
PA: diffuse tenderness , severe in epigastric region
A: ACUTE PANCREATITIS
P:
Liquid diet
IVF : NS , RL @ 100ml/hr
INJ. ZOFER 4mg IV /BD
INJ.PANTOP 40mg IV/BD
INJ.PCM 650mg po/TID
INJ.NEOMOL 1g sos(if temp >101 f )
INJ. OPTINEURON 1amp in 100ml NS IV/BD
INJ. TRAMADOL 1amp in 100ml NS IV/BD
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