20 year old female with abdominal pain and vomitings

 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 patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient centered online learning portfolio and your valuable comments on comment box are welcome." 

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 patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient centered online learning portfolio and your valuable comments on comment box are welcome." 


grandmother.


--No similar complaints in the family members.


GENERAL PHYSICAL EXAMINATION :


-- Patient was observed in a well lit room after having taken her informed consent .

- Patient was conscious, coherent, co-operative and well oriented to time, place and person.


- Moderately built and nourished 



-- Pallor, Icterus, Cyanosis, Clubbing, Generalized Lymphadenopathy, Edema are absent.


Vitals : 


Temperature - Afebrile

Respiratory Rate - 17 cpm

Pulse Rate : 80 bpm

Blood Pressure - 110/80 mm Hg

SpO2 - 100 % at RA

GRBS - 215 mg/dl 





SYSTEMIC EXAMINATION :


Per Abdomen :


On Inspection :


Abdomen is scaphoid not distended and the umbilicus is inverted.  






Provisional diagnosis:

Acute Pancreatitis  with DKA with Type 1 Diabetes Mellitus (since 3 years) secondary to hypertriglyceridemia


TREATME

 Day 1:-


1. Nbm till further order

2. IVF- NS & RL @ 150ml/hr

3. Inj HAI ( 39ml Normal Saline + 40 IU HAI ) @ 4 ml / hr according to Algorith

4. Inj. Pantop 40mg/IV/OD

5. Inj. Zofer 4mg/IV/OD

6. Inj. Tramadol 1amp in 100 ml/NS/IV/BD

7. Inj. THIAMINE 2amp in 1 NS/IV/TID

8. Monitor vitals

9. Measure abdominal girt

h.....m.s. NT dominal girth

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