30 year old male with acute pancreatitis with cholelithiasis.

CBBLE  UDHC SIMILAR CASE STUDY


C/O PAIN ABDOMEN SINCE 1 DAY

HOPI-PATIENT  WAS APPARENTLY ASYMPTOMATIC 1  DAY BACK,THEN HE DEVELOPED PAIN IN ABDOMEN WHICH IS SUDDEN IN ONSET,NON PROGRESSIVE,NON COLIKY TYPE,AGGREVATED WITH WALKING,RELIEVED PARTIALLY ON BENDING FORAERD POSITIONPOSITION,ASSOCIATED WITH VOMITINGS-10 to 12 EPISODES,BILIOUS,APPROX-10 ML PER EPISODE,NO AGGREVATING,RELIEVING FACTORS
NO H/O FEVER,TRAUMA
H/O ALCOHOL INTAKE 2 DAYS BACK.

PAST H/O-NOT A K/C/O DM,HTN,BA,EPILEPSY
NO H/O SIMILAR COMPLAINTS IN THE PAST 

FAMILY H/O-NO SIGNIFICANT FAMILY H/O 

PERSONAL H/O-PT IS MODERATELY BUILT AND MODERATELY NOURISHED
APETITE-NORMAL
BOWEL AND BLADDER MOVEMENTS REGULAR
ADDICTIONS-ALCOHOLIC SINCE 10 YEARS
QUANTITY-180 ML PER DAY
SMOKING CIGARETTES-SINCE 2 YEARS ,DAILY -3-4 CIGARETTES

GENERAL EXAMINATION-PATIENT IS CONSCIOUS ,COHERENT,COOPERATIVE

VITALS-
TEMP-AFEBRILE
BP-140/70 mmHg
PR-78
RR-17
SPO2-98 @Ra

S/E-
CVS-S1,S2 PRESENT
RS-BAE PRESENT
P/A-FLAT,NO DISTENSION,TENDERNESS PRESENT IN EPIGASTRIC REGION AND RIGHT PERIUMBILICAL REGIONREGIONS,NO GUARDING AND RIGIDITY,BS PRESENT
CNS-NAD

Investigations

DIAGNOSIS-ACUTE PANCREATITIS WITH CHOLELITHIASIS

TREATMENT-
1..NBM TILL FURTHER ORDERS.
2.IVF NS/RL @120 ML/HR
3.INJ ZOFERZOFER 4mg IV/TID
4.INJ PAN40 MG IV/OD
5.INJ TRAMADOL 1 AMP IN 100 MLNS/IV/SOS
6.ABDOMINAL GIRTH MONITORING




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