29 year old male diagnosed with acute on chronic pancreatitis
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A 29 yr old male patient came to the opd with cheif complaints of
Pain abdomen since 3 days associated with tightness of abdomen
Vomitings since 3 days .
HOPI
Patient is apparently asymptomatic 3 days back then he developed pain abdome associated with tightness of abdomen Vomitings which is non projectile and non bilious.
No H/o of fever, body pains , headache ,diarrhea
H/o of outside consumption of food 2 days back
PAST H/O
K/c/o pancreatitis 2018,2020 -2 episodes
Not a k/c/o diabetes ,HTN, TB,asthama,cvd , epilepsy.
PERSONAL H/o
diet - mixed
Apetite - normal
Bowel ,bladder movements - regular
Sleep - adequate
Addictions - h/o of smoking stopped 2 yrs back.
FAMILY H/O
No significant family h/o
GENERAL EXAMINATION
patient is conscious, Cooperative, coherent, oriented to time, place, person
Vitals
Bp 130 /70 , HR 86 ,PR 22, GRBS 125, spo2 98%
No pallor
No cyanosis
No clubbing
No icterus ,
No edema
No Lymphadenopathy
SYSTEMIC EXAMINATION
Cvs
S1 s2 heard no murmurs
Respiratory system
Normal vesicular breath sounds, no wheeze , no dyspnea , trachea is central
Abdomen
Shape of abd - scaphoid
Tenderness - present
No palpable mass, fluid , bruit
No palpable liver , spleen
P/V , P/R NORMAL
CNS
Patient is conscious , speech normal, no meningeal signs
Cranial nerve ,Sensory, motor examination ,reflexes , gait normal , no cerebral signs
PROVISIONAL DIAGNOSIS
acute on chronic pancreatitis
INVESTIGATIONS
CUE , CBP ,serum amylase ,serum lipase,ECG,HIV ,HBsAg,HIV .
TREATMENT:-
1) INJ ZOFER 4MG
2)INJ PAN 40 MG
3)INJ TRAMADOL 1 AMP IN 100 ML NS
4)REVIEW SOS
5)BP ,PR ,SPO2 monitoring
6)IVF 1Q NS
1QRL
1Q DNS
