CHRONIC PANCREATITIS WITH PSEUDOCYST

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's 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 centered online learning portfolio and your valuable inputs on comment box is welcome . 

A 27 year old male patient who is electrician by occupation came with a chief compliant of abdominal pain since 3 months

HISTORY OF PRESENT ILLNESS :-

Normal routine of patient: He used to wake up around 7 in the morning and have breakfast (rice) at 9 am and then go to work and return around 8 in the night.He used to consume alcohol almost everyday

Patient was asymptomatic three months back and then developed a mild diffuse abdominal pain in the left hypochondrium region

Later he developed the pain which was radiating to the back and he was admitted in the government hospital where in after the treatment the pain subsided 

The pain was felt again by the patient after a week in the hypochondrium and epigastric region which was intermittent squeezing type,radiating to the back and was admitted in our hospital.

Aggregating factors - food 

Relieving factors - medication 

Type of pain - squeezing 

 It is not associated with nausea,vomiting,burning micrurition,diarrhoea.

He was also having chest pain with burning type since 3 months 

HISTORY OF PAST ILLNESS:-

The patient was not a known case of diabetes,asthma,tuberculosis,epilepsy.

PERSONAL HISTORY :-

• Diet - mixed 
• Sleep - inadequate 
• Bowel and bladder - regular 
• Addictions- chronic alcoholic since 4 years but had stopped alcohol intake since four months 

FAMILY HISTORY :-

Insignificant 

GENERAL EXAMINATION:-

-Patient is conscious and cooperative 

-No clubbing 

-No pallor 

-No Icterus

- No lymphadenopathy 

-No edema of feet 

-No cyanosis 

VITALS :-

• Temperature - afebrile
• Pulse rate -84bpm
• BP - 100/80 mm hg
• SpO2 - 99% on RA 

SYSTEMIC EXAMINATION :-

CVS : S1 S2 +

Respiratory : difficulty in breathing when the pain sets in.

P/A :- tenderness present in the epigastric and left hypochondrium region  

Bowel sounds present 

INVESTIGATIONS :-

Ultrasound impression - cystic lesion with hyperechoic

component in the body of pancreas

Multiple cystic lesions and thick internal echoes noted

at left upper quadrant

TREATMENT GIVEN :

1) IVF NS /RL @75 ml / hr

2) inj Tramadol 100 ml IV /TID

3) inj pantop 40 mg iv/ OD

4 ) inj zofer 4 mg iv/sos

5) plan to get CECT abdomen today and also gastro Opinion.