67 year old recently diabetic with pain abdomen since 4 days

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I have 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 diagnosis and treatment plan

Patient came to OPD with chief complaints of pain abdomen since 4 days

HOPI :  

Patient was apparently asymptomatic 4 days back then he developed pain in the abdomen, insidious in onset, gradually progressive dragging type,aggravated on doing work ,after consumption of alcohol ,not associated with nausea,vomitings

No h/o fever,cold,cough

No h/o constipation ,diarrhea

H/o burning micturition

H/o sob grade 2 mmrc 

No h/o palpitations,edema, PND, ORTHOPNEA.

Past history 

N/k/c/o HTN, Asthma, epilepsy,TB , CAD,CVA

No h/o surgeries in the past 

No H/O blood transfusion 

No h/o radiation exposure

Personal history: patient is farmer by occupation 

Diet mixed

Appetite decreased since 4 days 

Sleep adequate

Bowel regular 

Micturition not normal 

Burning micturition

SLEEP ADEQUATE.

Addictions regularly consumes alcohol about 90 ml/day 

Since 30 years 

General physical examination

Pt is conscious coherent cooperative well oriented to time place person

Moderately built and nourished

Vitals

Bp : 130/80 mm Hg 

Pr :  69 bpm

Spo2 98 on RA 

Temp:  98.3 F

Grbs 197 mg/dl

No pallor, cyanosis, clubbing, lymphadenopathy,edema

Icterus present 

Systemic examination : 

Cvs s1 ,s2 heard

CNS no focal neurological deficits noted

Rs BAE + , NVBS 

P/A 

Inspection : abdomen flat 

No scars,sinuses,hernial orifices, pulses,masses,

All quadrants are moving equally with respiration

On palpation: 

All inspectory findings are confirmed 

Abdomen soft 

Tenderness in epigastric and both hypochondriac regions

No local rise of temperature

Guarding+ 

Rigidity absent

Provisional diagnosis : acute on chronic pancreatitis

Investigations done on 27/11/23 

CBP : 

Serum lipase 

LFT 

AMYLASE 

PT 

RBS 

USG ABDOMEN AND PELVIS 

x ray erect abdomen 

Chest x ray : 

Investigations done on 28/11/23 

Final diagnosis : 

Chronic pancreatitis

SOAP NOTES: DAY 1 

S : c/o pain abdomen

No nausea, vomitings 

No fever spikes 

O : O/E  pt is c/c/c 

Temp 

PR. 69 bpm

Bp. 120/70 mm hg 

Spo2 97 % at RA

GRBS 192 mg/dl

RS BAE + ,NVBS,No added sounds 

P/A : Guarding+ , tenderness+ bowel sounds heard 

Cvs s1,s2 heard 

No murmurs

CNS  NFND

A : acute on chronic pancreatitis 

P: NBM untill further orders 

IVF ns @ 100 ML/hr 

Inj ceftriaxone 2 g /IV / BD 

INJ METROGYL 500 mg IV /TID

Inj thiamine 200 mg in 100 ML NS IV/tid 

Inj Tramadol 100 mg in 100 ML NS IV/BD 

INJ PAN 40 Mg IV /OD 

INJ ZOFER 4 Mg IV /BD

Day 2 

S : c/o pain abdomen reduced

No nausea, vomitings 

No fever spikes 

O : O/E  pt is c/c/c 

Temp 

PR. 84 bpm

Bp. 110/70 mm hg 

Spo2 97 % at RA

GRBS 108 mg/dl

RS BAE + ,NVBS,No added sounds 

P/A : Guarding+ , tenderness+ bowel sounds heard 

Cvs s1,s2 heard 

No murmurs

CNS  NFND

A : acute on chronic pancreatitis 

P: NBM untill further orders 

Inj ceftriaxone 2 g /IV / BD 

INJ METROGYL 500 mg IV /TID

Inj thiamine 200 mg in 100 ML NS IV/tid 

Inj Tramadol 100 mg in 100 ML NS IV/BD 

INJ PAN 40 Mg IV /OD 

INJ ZOFER 4 Mg IV /BD