ACUTE PANCREATITIS WITH AKI
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I've 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 a diagnosis and treatment plan.
CASE:
A 40 year old Male came to the causality with chief complaints of vomiting and abdominal pain since three days.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic three days back then he had a heavy fatty meal followed by vomiting 4- 5 episodes which has food as content , non- bilious, non- projectile.
He also complained of pain in upper abdomen which is insidious in onset , squeezing type , non radiating, aggravated on food intake and relieved after episode of vomiting and on bending forward.
No history of loose motions, fever, decreased urine output, shortness of breath, pedal edema, chest pain, numbness, muscle spasms.
PAST HISTORY:
He had similar complaints 6 months back for which he was treated in our hospital.
Not a known case of diabetes, hypertension, asthma, epilepsy , tuberculosis.
Past surgical history- appendectomy 20 years back.
PERSONAL HISTORY:
Appetite- normal
Diet- mixed
Bowel and bladder- regular
Sleep - adequate
Addictions -
history of alcohol intake from 15 years , 180 ml per day , abstinence from 1 month.
CAGE criteria: score - 1
- Have you ever felt you needed to Cut down on your drinking - no
- Have people Annoyed you by criticizing your drinking - no
- Have you ever felt Guilty about drinking - no
- Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover - Yes
History of Smoking from 15 years , 4- 5 cigarettes per day.
No history of drug and food allergies.
FAMILY HISTORY: insignificant
GENERAL EXAMINATION:
patient was examined in a well lit room after taking consent.
Patient is conscious, coherent and cooperative.
pallor - absent
icterus - absent
Cyanosis - absent
Clubbing - absent
No lymphadenopathy
No pedal edema.
Vitals:
Temperature: 99F
BP :160/110 mmHg
PR : 98bpm
RR: 22 cpm
SpO2 98% in room air
SYSTEMIC EXAMINATION:
CVS: S1 S2 heard
No thrills and murmurs
RS : trachea central
BAE- present
Normal vesicular Breath sounds
CNS: No focal neurological deficits
P/A : soft , non tender
Umbilicus - inverted
All quadrants moving equally with respiration
Scars- vertical scar seen below umbilicus on right side ( appendectomy scar)
No palpable spleen and liver
Normal bowel sounds heard.
INVESTIGATIONS:
CBP:
Hb - 12.3 gm/dl
TLC - 9400 cells/ cumm
RBC - 4.5 million
PLT - 4.5 lakh
PCV- 37.7
Amylase - 79 IU/L
Lipase - 28 IU/L
RFT:
urea - 79 mg/dl
Creatinine - 1.5 mg/dl
eGFR - 51.8
Electrolytes:
Na - 145 mEq/L
K - 4.1 mEq/L
Cl - 98 mEq/L
LFT :
Total bilirubin- 1.36 mg/dl
ALT - 26 IU/L
AST - 38 IU/L
ALP - 153 IU/L
albumin - 3.5 gm/dl
A/ G ratio - 1.35
CUE :
Clear, pale yellow
Pus cells : 3 - 4
Albumin - nil
RBC , casts - nil
X- RAY
USG :
ECG :
PROVISIONAL DIAGNOSIS:
Acute pancreatitis with Acute kidney injury
TREATMENT:
Day 1
- IV Fluids - NS and RL - 100 ml/hr
- Inj. PAN - 40 mg IV , OD
- Inj. BUSCOPAN - 10 mg , IV
- NBM
- GRBS monitor
- BP monitor 4 hrly
- Monitor I/O
