39 yr old male with acute pancreatitis?
C/O-PAIN ABDOMEN SINCE 45 days, EPIGASTRIC,DRAGGING TYPE OF PAIN
HOPI-PT WAS APPARENTLY ASYMPTOMATIC 45 DAYS AGO THEN HE DEVELOPED PAIN ABDOMEN(EPIGASTRIC REGION) ASSOCIATED WITH NAUSEA AND LOSS OF APETITE
NO VOMITINGS
NO COMPLAINTS OF CONSTIPATION/OBSTIPATION
NO JAUNDICE
PAST HISTORY-N/K/C/O DM,HTN,BA,EPILEPSY
NO H/O SIMILAR COMPLAINTS IN THE PAST
FAMILY H/O -NO SIGNIFICANT FAMILY HISTORY
PERSONAL H/O-
PT IS MODERATELY BUILT AND MODERATELY NOURISHED
BOWEL AND BLADDER MOVEMENTS REGULAR
H/O ALCOHOL INTAKE-REGULAR,TODDY SINCE 15 YEARS,WHISKY 250 ML ONCE IN 2 DAYS FOR 1 YEAR.
No OTHER ADDICTIONS
GENERAL EXAMINATION-
PT C/C/C
NO PALLOR/ICTREUS CYANOSIS/EDEMA/LYMPHADENOPATHY
VITALS-
TEMP-AFEBRILE
BP-110/80
PR-90
RR-20
SPO2-98% AT RA
SYSTEMIC EXAMINATION-
CVS-S1,S2 HEARD,NO MURMURS
RS-BAE PRESENT,NVBS HEARD
P/A-SOFT,NONTENDER,BS+
CNS-NAD
DIAGNOSIS-
ACUTE PANCREATITIS?
TREATMENT-
1.IVF NS/RL/DNS -100 ML/HR
2.INJ PAN 40 MG IV/OD
3.INJ ZOFER 4MG/IV/SOS
4.INJ TRAMADOL 1 AMP/IV/SOS IN 100 ML NS
5.INJ THIAMINE 1AMP IN 100 ML NS IV/OD
6.MONITOR VITALS AND INFORM SOS
Investigations-