40yr/F with acute pancreatitis

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A 40 yrs old female came to opd with chief complaint of

 acute history of pain abdomen & vomiting’s since 4 days  

HOPI

Patient was apparently asymptomatic 4days back now presenting with complaints of pain abdomen originated at left hypochondrium and lumbar region (VAS 7 score) then became diffuse in type over 10 to 12 hours (VAS 10)

Worst pain she ever had), squeezing type of pain with occasional coliky type, associated with vomiting’s 2-3 episodes non bilious , non-projectile, non-blood tinged with food particles as content. Passing stools small amount (as fecal pellets of goat - described by patient) didn’t pass flatus since 2 days. 

history of bloating, belching since 5 years using antacids. 

H/o Passage of hard stools since 2 months

Past history

K/c/o diabetes since 7yrs

Not a known case of htn, thyroid,tb, epilepsy.

Treatment history:

weekly she used to take 2-3 sachets of ENO (antacids)

Personal history:

Diet:mixed

Appetite -reduced

Bowel-constipation since 5months

Bladder -regular

No addiction 

MARRIAGE & OBSTETRIC HISTORY: 

 

Married at the age of 17 years , non-consanguineous. 

FIRST child at 18 years - death of the first child at 24years due to varicella zoster. 

2nd child at age of 21 years - gave birth to female child , now married 

3rd child at the age of 23 years -gave birth to female child , now married 

4th child at the age of 24years - gave birth to male child currently 10th class.

LMP-23/04/23

FAMILY HISTORY:

 Mother is hypertensive and expired due to cerebrovascular accident and post stroke complications after 6 months.

General examination

Patient is conscious, coherent Cooperative

Pallor present

bilateral pitting type of pedal Edema present with scratch marks on both lower limbs (pruritus due to possible diabetic dermopathy)  

No icterus, cyanosis, clubbing, lymphadenopathy.

She used to colour her hair since 8 years (early whitening of hairs at 28 years – probable zinc and other nutritional deficiencies)

Looks grossly dehydrated with sunken eyes, dry oral mucosa and tongue with delayed capillary refill time (more than 3 seconds)

SYSTEMIC EXAMINATION:

 

EXAMINATION OF THE ORAL CAVITY

NO Oral thrush, NO tonsilar enlargement & pharyngeal deposits, NO post nasal drip, NO fetor hepaticus, Fair oral hygiene, no dental caries and no gum hypertrophy.

 ABDOMEN

INSPECTION:

1. Shape – distended-uniform

2. Flanks – full

3. Umbilicus – central, Shape-slit like and nodules.

4. Skin – stretched, no scars & sinuses, striae present, scratch marks.

5. No Dilated veins – front/back

7. Movements of the abdominal wall,NO visible gastric & intestinal peristalsis.

8. Hernial Orifices - normal

9. NO Renal angle tenderness

PALPATION

Superficial Palpation – Tenderness present at left hypochondrium and lumbar region, no local rise in temperature.

Deep Palpation

1. Liver: inferior edge palpable, smooth non nodular.

2. Spleen non palpable and non-tender when palpated in the Left Hypochondrium.

3. Kidney non-tender and non palpable in the Right/Left Lumbar.

4. Abdominal Girth - 79cms

5. Distance between the Xiphisternum-Umbilicus and Umbilicus-Pubic Symphysis equal 17 cms.

6. No Murphy’s Punch/Renal angle tenderness.

 

PERCUSSION:

1. Puddle’s sign present suggestive of mild fluid collection in abdomen.

2. Percussion of Liver for Liver Span - 13cms

AUSCULTATION:

1. Bowel sounds – sluggish

2. No Bruit – Aortic, Hepatic, Renal Bruit

3. No Venous Hum.

CARDIOVASCULAR SYSTEM:

No raised Jugular venous pressure

Apex beat in 5th Intercostal space on left mid clavicular line

S1 and s2 heard. NO murmurs.

EXAMINATION OF RESPIRATORY SYSTEM:

No tracheal deviation

Respiratory movements are bilateral symmetrical

Resonant percussion in all lung field’s

Normal vesicular breath sounds.

 EXAMINATION OF NERVOUS SYSTEM:

Higher mental functions intact

All Cranial nerves on both sides are intact

No motor deficits

Sensory system :

Fine touch - absent below both ankles

Vibration - delayed in both lower limbs ( 6sec at ankle, 8 sec at knee ) and upper limbs ( 9sec in upper limb )

Gait normal

Gastroenterologist consultation was taken : 

Advised for IgG4 antibodies , ANA and MRCP.

Investigation

Provisional diagnosis

Acute pancreatitis secondary to triglycerides with acute kidney injury , hypokalaemia 

Diabetic nephropathy 

Treatment:

NBM till further adress

Iv fluids 10ns@100ml/hr

Inj.pan 40mg /iv/od

Inj.zofer 4mg /iv/sos

Inj.optineuron 1amp in 500mlns/iv/od

Inj.neomol 1gm/iv/sos

Inj .metrogyl 500mg /iv/tid

Inj.ciproflox 200mg /iv/bd

Tab.sporalac 2tabs /po/tid

Monitor vital hrly

Inj.tramadol 1amp on 100ml ns /iv/sos

Strict i/o charting

Discharge summary 

 she was referred to higher centre as she is clinically deterioration of symptoms and need for MRCP and patient and patient atternder explained about the need of MRCP

In our hospitals we done all the requried investigation and given symptomatic treatment

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