A 32 year old male patient who is a resident of mothkur came to the OPD with chief complaints of pain abdomen since 3 days, 1 episode of vomiting 2 days back



History of present illness:

Patient was asymptomatic 4 years back then developed pain abdomen which was relieved by medication.


Then 3 days back , he developed pain abdomen in epigastrium, left hypogastrium, and lumbar region along with 1 episode of vomiting which is green in color (bilious).

He complains of loss of appetite since 2days.

He complains of constipation since 2 days.


History of past illness:

N/K/C/O Hypertension, diabetes mellitus, epilepsy , asthma ,CAD Tuberculosis.

No relevant surgical history.

PERSONAL HISTORY :

Married

Diet - Mixed

Appetite - decreased

Bowel and bladder movements - Irregular

Sleep - adequate

Addictions - chronic alcoholic.


FAMILY HISTORY :

No significant family history.



GENERAL PHYSICAL EXAMINATION :

Patient is Conscious,Coherent, Not co operative. Moderately built, moderately nourished.
Well oriented to time,place, person.


Pallor -

Icterus +

Cyanosis -

Clubbing -

Lymphadenopathy -

Edema -



VITALS

BP - 110/80

PR - 72 bpm

RR - 16cpm

TEMP - Afebrile

SPO2 : 96% on room air.

GRBS : 88 mg %




SYSTEMIC EXAMINATION :


CVS : S1 S2 heard ,no murmurs heard

RS : BAE + , NVBS +

CNS : No focal neurological deficits.

PA :  Soft, Tender.

INVESTIGATIONS : 










X RAY : 








ULTRA SOUND REPORT : 










PROVISIONAL DIAGNOSIS :

Acute pancreatitis.



TREATMENT : 

INJ PAN 40 mg /IV /OD

INJ ZOFER 4 mg /IV / SOS 

INJ THIAMINE  1 AMP in 100ml NS  IV / TID 

INJ TRAMADOL 1 AMP in 100ml NS / IV / SOS

 IVF - NS ,DNS,RL  at 100 ml / hr .





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