Varshitha’s ELOG

August 17 2020

Hello everyone.. I am varshitha , an intern posted in medicine department and one of the important terms of getting the internship completion is to complete my log book with my online log of what I learn during the course of my duties.

Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.

This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome

Here is a case I have seen-

 A 34 year old male  came to the hospital with the chief complaint of pain abdomen since 2 days,vomitings since a day

History of presenting illness- 

Patient was apparently asymptomatic 6 months back then he developed pain abdomen and abdomen distension for which he went to a hospital and was diagnosed there as acute necrotising pancreatitis and was treated conservatively ,he has stopped drinking alcohol 6 months back.Patient complained of pain abdomen since 2 days  and his last binge was 6 days back 

Past history-

Not a k/c/o hypertension , diabetes mellitus, asthma, epilepsy, cad

No past surgical history

Family history-

Not significant

Personal history - 

he has a mixed diet with a normal appetite , adequate sleep, regular bowel and bladder movements

Chronic alcoholic (90ml/day)since 6 years,but stopped 6 months back , his last binge was 6 days back

General examination-

Patient is concious , coherent, cooperative, moderately built and nourished 

Vitals- temp -afebrile , Bp- 130/80 mmhg pr- 82bpm rr- 17 cpm

No pallor , icterus, cyanosis, clubbing,pedal edema , lymphadenopathy

P/A - 

shape - distended, no local rise of temperature, diffuse tenderness present ,no guarding, no rigidity,no organomegaly, hernial orifices are free

CVS- 

S1 S2 hears, no murmurs

RS- 

Shape- normal, NVBS heard, trachea midline, no wheeze, no adventitious sounds

CNS-

higher mental functions- normal

 Motor system- intact

 Sensory system - intact

cranial nerve examination - normal

INVESTIGATIONS

OTHER INVESTIGATIONS

ECG

13/08/2020

14/08/2020

USG ABDOMEN

REVIEW USG ABDOMEN  16/08/2020

   CHEST XRAY

                  13/08/2020

                    16/08/2020

                     17/08/2020

               CECT ABDOMEN

    DIAGNOSIS -  ACUTE PANCREATITIS SECONDARY TO ALCOHOL 

TREATMENT

     

1. NBM till further orders
2. IVF 10 NS  10 RL  10DNS @100ml/hr 
3. Inj. pan 40 mgIV OD
4. Inj zofer 4 mg IV sos 
5. Inj tramadol (1 amp)100 ml NS IV TID
6. monitor vitals Bp Rr Spo2 PR
7. grbs charting hourly

Course in the hospital

          INPUT /OUTPUT CHARTING

                            15/08/2020

INPUT - 4500ml        OUTPUT - 4190ml

                     16/08/2020

INPUT -3700ml        OUTPUT- 3200ml

                       17/082020

INPUT -1200ml.         OUTPUT -1800ml

                       18/08/2020

INPUT- 1950ml.        OUTPUT-1400ml

                           19/08/2020

INPUT - 2100ml             OUTPUT-500 ml