32M

 Unit 2 admission:

32 year old male lorry driver by occupation came to casualty with chief complaints of pain in abdomen since one day.

Patient was apparently asymptomatic 1 day ago.

Patient had alcohol intake today morning (14/09/21), and had food in the afternoon.

 Then he developed pain in abdomen at umbilical region, throbbing type, non radiating, aggravated after food intake, not associated with nausea, vomiting , constipation and loose stools, No

History of fever and burning micturition.


Not a known case of hypertension diabetes epilepsy tuberculosis asthma.


O/E:

vitals: temperature AFEBRILE, pulse rate 88 BPM, respiratory rate 16 CPM , BP 130/80 mm Hg, spo2 98% at Room air.

CVS : S1 S2 heard

RS: BAE+ NVBS +

PA: obese abdomen, tenderness in gastric and hypochondrial region, bowel sounds present.


Provisional diagnosis:

Acute pancreatitis? Secondary to alcohol dependence


Investigations 


Amylase - 45 IU/L

Lipase - 23 IU/L

Ultrasound - 

altered echotexture of body of pancreases

GB sludge 

ALP - 184 IU/L

Diagnosis- acute on chronic pancreatitis with k/c/o DM ( pancreatic - exocrine insufficiency)

Treatment:

Day1

Soft oral diet

IVF - NS, RL, DNS

injection pan 40 mg

Inj  optineuron 1amp in 100ml NS

Inj Thiamine 1 amp in 100ml/NS/IV/BD

Inj Tramadol 1 amp in 100ml/NS/IV/SOS

Day 2

Soft oral diet

IVF - NS, RL, DNS

injection pan 40 mg

Inj optineuron 1amp in 100ml NS

Inj Thiamine 1 amp in 100ml/NS/IV/BD

Inj Tramadol 1 amp in 100ml/NS/IV/SOS

Day3

Soft oral diet

IVF - NS, RL, DNS

injection pan 40 mg

Inj  optineuron 1amp in 100ml NS

Inj Thiamine 1 amp in 100ml/NS/IV/BD

Inj Tramadol 1 amp in 100ml/NS/IV/SOS


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