A 32 YEAR OLD MALE WITH PAIN ABDOMEN

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CASE: 

A 32 Year old male came to the OPD on 29/10/2021 with Pain Abdomen.

CHIEF COMPLAINTS:

1. Pain abdomen since one day

2. Vomiting since one day (2 episodes)

3. Constipation since one day

HOPI:

Patient was apparently asymptomatic 4years ago (2017) , after which he developed PAIN ABDOMEN and was taken to a local hospital and he was diagnosed with ACUTE PANCREATITIS and treated for the same, was asked to stop consumption of alcohol and discharged.

Patient continued to consume alcohol occasionally.

2021 September- he again developed symptoms and  was taken to hospital and waa treated.

29th October 2021-

Patient came to OPD with

•  PAIN ABDOMEN-Epigastrium and left hypochondrium since 1 days; squeezing type, Sudden in onset and gradually progressive 

Aggravated on drinking and no relieving factors.

There is no positional and diurnal variation. 

• VOMITING-associated with nausea and vomiting; 2 episodes, non- projectile, non- bilious, contents are food particles
• CONSTIPATION- since one day
• SOB- Grade IV
• No h/o Fever

PAST HISTORY:

Not a K/C/O - DM, HTN, Epilepsy, Asthma, TB, CVA.

PERSONAL HISTORY: 

1. Diet- MixedA
2. ppetite- Loss of appetite is present.
3. Bowel and bladder movements- Regular
4. Sleep- Adequate
5. Addictions- H/o alcohol consumption (beer) since 5 years, 2 times a day, stopped 1 month ago.
6. Surgical history: no h/o previous surgeries.

FAMILY HISTORY:

Insignificant 

GENERAL EXAMINATION:

The patient was examined in a well-lit room after informed consent was taken.

He is conscious, coherent, cooperative, well oriented to time, place and person.

He is well nourished and moderately built.

No Pallor, Icterus, Clubbing, Cyanosis, Koilonychia, Lymphadenopathy, Edema.

VITALS:

1. Temperature- Afebrile
2. PR- 90 bpm
3. RR- 18 cpm
4. BP- 100/70 mmHg

SYSTEMIC EXAMINATION:

1. CVS: S1, S2 Heard
2. RS: BAE+, NVBS
3. P/A: shape- scaphoid, soft, tenderness is present in the epigastric region., Bowel sounds heard, no palpable mass, no free fluid, no bruit.
4. CNS: Intact

INVESTIGATIONS:

COMPLETE BLOOD PICTURE

SERUM AMYLASE

SERUM LIPASE

COMPLETE URINE EXAMINATION

SERUM ELECTROLYTES

SERUM CREATININE

LIVER FUNCTION TEST

LDH

BLOOD UREA

SERUM CREATININE

HIV TEST REPORT

HEPATITIS B

HEPATITIS C

ULTRASOUND 

ECG

HEMOGRAM

COLOUR DOPPLER 2D ECHO

PROVISIONAL DIAGNOSIS:

Acute Pancreatitis 2° Alcohol

TREATMENT:

1. IVF- NS,RL-150ML/HR
2. INJ.PAN.40MG/IV/BD
3. INJ. THIAMINE 200MG IN 100ML NS /IV/BD
4. INJ.OPTINEURON 1AMP IN 100ML NS/IV/OD
5. INJ.TRAMADOL 1AMP IN 100 ML NS/IV / B
6. INJ.ZOFER 4MG /IV/BD
7.   strict I/O monitoring 
8. BP,PR, SPO2 Monitoring 4th helt
9. GRBS monitoring 6hrly
10. inform sos