A 36 year old male with acute pancreatitis

36 year old male with epigastric pain

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Case History

CHIEF COMPLAINTS -

A 36 year old male , driver by occupation ,came to the casualty with cheif complaints of


-Pain in the epigastric region since 9 days 


HISTORY OF PRESENTING ILLNESS -


Patient was apparently asymptomatic 9 days c/o sob since 5 days (grade 2 )   h/o complains of epigastric pain since 9 days which is sudden in onset non-radiating type , history of   back pain since 4 days , and constipation since 4 days  and decrease in appetite. 


complains of belching 2 to 3 times per day 

He had similar episode previously in June 2021 with complaint of pain and distended abdomen. 

no history of nausea, vomiting , no h/o loose stool ,no history of past surgery 
no history of jaundice previously 
no history of gallstones, 


PAST HISTORY - 

Similar history 6months back , not a known case of htn , dm , epilepsy , asthma , tb
no previous surgical history 
no history of gallstones in the past


PERSONAL HISTORY :


Diet - mixed 

Appetite -decrease appetite ,

Bowel movement - irregular since 3 days, bladder movements - regular , Addictions(alcohol and smoking) - 
alcoholics in seven years takes at least 150 ml 
occasional toddy user also since six months drinks 180 ml per day 
no history of smoking or chewing tobacco
 brand used it is (royal stag or ib )180 ml per day is in six months


FAMILY HISTORY - 

not significant


GENERAL EXAMINATION -


Patient is concious , coherent ,cooperative ,well oriented to time ,place and person.
no pallor , icterus , clubbing , cyanosis , lymphadenopathy , edema



vitals - 


temperature - afebrile

pulse rate - 97 bpm

blood pressure - 100 /70 mm of hg 

respiratory rate - 22

spo2 - 98% at room air


SYSTEMIC EXAMINATION - 


cardiovascular system : s1 and s2 heard , no murmurs
respiratory system : bilateral air entry present ,normal vesicular breath sounds
central nervous system : nad

p/a -
Abdomen is slightly distended
pain in the epigastric region and 
pain is more in the right iliac and lumbar region
no bruit’s , no gaurding, no rigidity
negative cullens sign and grey turners sign, no fox's sign
bowel sounds present 

On 9-1-22

INVESTIGATION - 

ECG:

HEMOGRAM: 




CUE:



RFT:



Serum amylase - 223 u/l

Serum lipase - 86.1 u/l

CT scan

COMPLETE URINE EXAMINATION: 

PROVISIONAL DIAGNOSIS -

Acute pancreatitis
With alcohol dependence

TREATMENT GIVEN -

1 . ivf ns and rl and dns @ 50 ml /hr

2. ink . pantop 40 mg iv/od

3 .ink zofer 4 mg iv sos

4. inj tramadol 1 amp in 100 ml na iv bd

5.inj buscopan 22 cc iv/sos

6.tab pcm 650 mg po/tid 

7.grbs 6 th hourly

8 temp and i/o charting