A 38 year male patient with acute pancreatitis
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A 38 years old male patient came to opd with cheif complaint of pain in abdomen since 4 days
Patient was associated with nausea and vomiting since one Week
He started consuming alochol(toddy)90ml once in three to four days
History of present illness:
Patient is apparently Normal 4 years back .
two years back patient has visited local hospital with complaint of pain in abdomen and he was admitted in hospital for alocholic liver diseases and got discharged
Patient again started consuming alcohol for three months and had a similar complaints and got admitted in hospital
Ten days back patient has alcohol binge presented with pain in abdomen nausea and vomiting
Has a mild pleural effusion one month back
History of past illness:
No Dm
No HTN
No EPILEPSY
No asthama
Personal history :
Diet:mixed diet
Sleep: adequate
Apetite :normal
Bowel n bladder movements :regular
Micturition normal
Habits: alcoholic and smoking
Drug history:
Patient was not allergic to any known drugs
Family history: there is no history of similar complaints of family members
General examination:
Patient is conscious coherent co-operative he is well oriented to time place and person
Built: moderately built and well nourished
No pallor
No cyanosis
No clubbing
No lymphadenopathy
No pedal edema
Temperature: Afebrile
Pulse rate:70/min
Respiratory rate:18/min
Bp:110/80
Spo2:98%
Systemic examination:
Cvs:
Insepction :chest wall is bilaterally symetrical
No precardial bulge
No visible pulsations
No engroaged veins
Palpation:jvp normal
Apex beat felt in left 5th intercostal space in mid clavicular line
Auscaltation:s1 s2 heard
Respiratory system:
Bilateral airway (+)
Position of trachea
Normal vesicular breath sounds heard
No added sounds
Per abdomen:
Abdomen is soft and tender
Mild ascities
Minimal perispleenic loculated fluid present
No palpABle masses
Herinial orifices normal
No free fluid
No bruits
Liver 'not palpABle'
Spleen " not palpable'
Bowel sounds heard
CNS:
Patient is conscious alert
Reflex are normal
Speech is normal
Provisional diagnosis:
Acute edematous intestinal pancreatitis
Treatment:
Inj Pan -40mg
Inj zopher
Inj thiamine
Ivs ns 500ml(100ml/hr)
Inj Tramadol 1 ampule in 100ml ns
Monitor vital signs.
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