Acute case of pancreatitis

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Chief complaints 

Patient came to the casuality with complaints of 

  pain abdomen since 7hrs

Diffuse pain all over abdomen 

Sudden in onset,non progressive 

Patient was aymptomatic 7hrs ago when he had pain abdomen which was diffuse ,sudden in onset,non progressive,dull achivy type

ass/c 1 episode of lose srools on the same day 

No c/o vomitings,fever,SOB

History of presenting illness

Last alochol intake:2dyas ago-90ml

Occasional drinker 

Pt  had alcohol intake daily 

No other addictions

History of past illness

Had similar complaints in the past in 2019

N/K/C/O DM,HTN,TB,thyroid disorders,epilepsy

Personal History

Married 

Photographer by occupation 

Diet: mixed 

Appetite:Normal 

Bowel bladder moments: regular

Addictions : Alcohol consumption 90ml per day

Family history

Not significant

On examination

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

No signs of pallor,icterus,clubbing,cyanosis,lymphadenopathy,pedal oedema 

Vitals

Temp:98.4*F

PR:67

Rr:21/ min

Bp:140/100

Spo2:99%

GRBS:129mg%

Systemic examination

CVS: S1,S2 heard, no murmurs heard 

Resp:NVBS heard 

Abdomen: 

Scaphoid in shape abdomen

Tenderness present,no palpable mass 

Bowel sounds present 

CNS :NAD 

Investigations:

LFT 

TB: 2.04mg/dl

DB:1.09mg/dl

AST:37IU/L

ALT:24IU/L

ALP:173IU/L

Blood urea :37mg/dl

RBS:127mg/dl

Uric acid:6.1mg%

Hemogram 

ECG 

Ultrasound report :

Pancreas showing altered echotexture of body

No ascitis 

No lymph adenopathy 

Bladder minimally distended 

Pelvis couldn't be assessed 

PROVISIONAL DIAGNOSIS:

ACUTE PANCREATITIS

TREATMENT PLAN :

1.IVF with NS,RL,DNS@ 150ml/hr 

2.NBM till further order

3.INJ  PANTOP 40mg IV/BD

4.INJ ZOFER 4mg IV/TID

5.INJ TRAMADOL 1AMP in 100ml NS IV/TID

6.INJ BUSCOPAN 2CC IV

7.I/O- CHARTUNG 

8.TEMP-CHARTING 

9.GRBS- 6th hrly