MEENAKSHI EMERGENCY HOSPITAL

Dr. G. Mallikarjuna Dr.M.V. Sai Niharika

MBBS, MEM( EMERGENCY MEDICINE) MBBS,MS(GENERAL SURGERY)
(GWU-USA), MRCEM(UK)
Fellowship in clinical toxicology,
Sr. Consultant in PES medical college
( Kuppam ) APMC: 69643
Name of the patient: RAJENDRA PRASAD.G (EX.HAV-MACPNB/SUB NO:15313333W. Date: 13/09/2022

AGE: 46 YEARS /MALE.

DISCHARGE SUMMARY
 PROVISIONAL DIAGNOSIS: ACUTE PANCREATITIS
CHOLELITHIASIS
RIGHT RENAL CALCULUS .
 TREATMENT: CONSERVATIVE MANAGEMENT.
 H/O PRESENT ILLNESS: Patient came to EMERGENCY DEPARTMENT on 09/09/2022 at 4
am with severe abdominal pain.
 H/O Abdominal pain insidious onset, radiating to back, associated with
vomiting, not relived with medications.
 H/O vomiting sudden onset, non bilious associated with abdominal pain.
 NO H/O breathlessness.
 NO H/O chest pain.
 PAST H/O:
Similar complaints in past [acute pancreatitis] for which he took treatment &
got admitted in past
 PERSONAL H/O:
 Not a known cause of type II diabetes mellitus.
 Stopped medications for HYPER TENSION some years back [ENALAPRIL
5 mg].
 A/T ( AT THE TIME OF ADMISSION): JAUNDICE,
DEHYDRATION,
NO PEDAL EDEMA.
 BP : 200/120 mmHg
 SPO2 : 95%
 PR : 94 B/M
 RR : 20 B
 TEMP : 98.6 F.
 A/T : TENDERNESS [DIFFUSELY]-More in Epi gastric region and right hypo chondrium .
 Guarding.
 No organomegaly.
 No mass palpable .
 No peristalisis .
 No Hernial arifices.
 INVESTIGATIONS ENCLOSED :
 COURSE IN HOSPITAL :
Patient by name RAJENDRA PRASAD .G come to EMERGENCY
DEPARTMENT on 09/09/2022 at 4am with severe abdominal pain associated with vomiting , got
admitted in to emergency department. All accessory investigations done. Patient was
diagnosed as ACUTE PANCREATITIS with HYPERTENSION [ B P >200/120mmHg ], for which RYILS
TUBE ASPIRATION done , patient kept NPO, patient was given IV fluids, IV antibiotics, IV
analgesics,O2 administration.
On day 2 of admission pain got reduced complain of ABDOMINAL
DISTENSION, for which regular abdominal girth monitoring & flatus tube kept in rectum.
On day 3 patient under gone plain CT to look for any changes [ CT
severity score 4/10 moderate severity ] & to look for CBD stones.
On day 4 patient was symptomatically better & shifted to general ward
allowed orally clear liquids.
On day 5 patient was allowed liquid diet followed by soft diet. No H/O
of abdominal pain vomiting, patient passed stools & patient was stabilized.
Patient was advised for SURGICAL GASTRO ENTEROLOGIST opinion for further management
for CHOLELITHIASIS & for CHRONIC PANCREATITIS.
 GIVEN MEDICATION:
- NPO till further orders
- IVF: NS,5%Dextrose and RL
- INJ. CEFTRIOXONE + SULBACTUM 1.5 gm IV I-O-I
- INJ. METROGYL 100ml IV I-O-I
- INJ. PANTOP 40mg IV I-O-I
- INJ. EMECET 4mg IV I-O-I
- INJ. NEOMOL 1gm IV I-O-I
- INJ. DROTIN M IV I-O-I
- INJ.OVTREOTIDE 100mcg IV I-O-O
- INJ. BUTEROPHENOL 1mg IN 100ml NS SOS
- INJ. PANTOP INFUSION IN 100ml NS
- RT ASPIRATIONS: carry on 2ND Hourly.
- O2 ADMINIUSTRATION if SPO2 <94% .
- ABDOMINAL GIRTH MONITORING 4TH Hourly.
- MAINTAINING INPUT & OUTPUT CHART.
 DISCHARGE ADVICE:
 Maintaining balanced clear liquid diet.
 Avoiding alcohol and tobacco consumption.
 Advice patient for an opinion of GASTROENTEROLOGIST.
 To do FBS, PPBS, HB Ag after one week.