Acute Pancreatitis

 CASE OF A 45 YEAR OLD MALE WITH C/O ABDOMINAL PAIN

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This Is The Case I Have Been Given :


A 45 year old male driver by occupation came to the opd with 

C/o vomitings since one day

C/o pain abdomen since one day 


Patient was apparently asymptomatic 1 day back and then suddenly developed vomiting  10 episodes yesterday containing food particles, non bilious , non projectile for which he went to local hospital and was given  IV fluids and then developed pain abdomen in the epigastric region , around the umbilicus.Pain aggravates on leaning back from bending position , associated with sob , pain aggravates  on taking food.

He had 1 episode of vomiting today morning,watery,non bilious,non projectile.

No H/o similar similar complaints in the past


N/K/ C /O HTN,DM,TB,EPILEPSY,ASTHMA,THYROID


H/o chronic alcoholism - Started drinking from 15 years of age daily 90 ml of whiskey for 20 years and then increased his consumption to 180-200 ml since 2 years

H/o tobacco chewing since 20 years 

H/o smoking cigarettes one daily for 18 years 


Vitals @ Admission :

Temp: 98.6F

BP:120/70 mmHg

HR:80 bpm

RR: 18 cpm

GRBS: 103 mg/dL

SpO2: 98% on RA


General Examination:

Pt is c/c/c

No Pallor/Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema

Thyroid normal


Systemic Examination:

CVS: S1S2 heard, No murmurs

RS: NVBS, BAE+

CNS - NAD 


PA - Soft , Tenderness + 

Pain abdomen in the epigastric quadrant and around the umbilicus


Investigations and Reports -


19/05/2022









SEROLOGY- NEGATIVE 


SERUM ELECTROLYTES-  NA - 137 mEq/L

                                                K - 4.3 mEq/L

                                                Cl - 99 mEq/L


SERUM CREATININE - 0.8 mg/dl


SERUM LIPASE - 670 U/L


SERUM AMYLASE - 566 U/L


                                  20/05/2022




Psychiatry Refferal Done -


21-05-2022


                             22-05-2022




PROVISIONAL DIAGNOSIS


ACUTE PANCREATITIS 


TREATMENT


1) NBM Till further orders

2)IVF NS RL DNS } 125 ml/hr

3)INJ TRAMADOL 50 mg in 100 NS/TID

4)INJ PAN 40mg IV/OD

5)INJ THIAMINE in 100 NS IV/TID

DAY1

SOAP NOTES- AMC- BED 2 - DAY 

DOA: 20/05/2022



Pt c/o pain abdomen- Epigastric and Around the Umblicus

Vitals

Temp: 98.6

BP:120/70 mmH

HR:80 bp

RR: 18 cp

GRBS: 103 mg/d

SpO2: 98% on R


General Examinatio

Pt is C/C/C

No Pallor/Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edem

Thyroid normal


Systemic Examination - 

CVS: S1S2 heard, No murmur

RS: NVBS, BAE +

CNS: NAD

P/A: Pain abdomen in Epigastrium and around the Umblicus



Acute Pancreatitis 

P1) NBM Till further orders


2)IVF NS RL DNS } 125 ml/


3)INJ TRAMADOL 50 mg in 100 NS/T


4)INJ PAN 40mg IV/


5)INJ THIAMINE in 100 NS IV/TID








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