35 yr old with pain abdomen

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Here is a case i have seen:

CASE DISCUSSION

A 35 year old male who is a farmer came with the complaint of pain in epigastric region(after his last binge of alcohol) from past 6 days which was burning type,radiating to peri umbilical and not aggravated or relieved with food intake but was associated with nausea and vomitings.

Vomitings were non bilious,non projectile and was of food particles and not blood stained.


No H/o fever,loose stools,constipation,pedal edema,abdominal distention,facial puffiness.

PAST HISTORY:

He is not a k/c/o HTN,DM,CAD,TB,CAD. 

PERSONAL HISTORY :

Patient has alcohol use disorder and had a habit of taking alcohol from past 6yrs with daily intake of 1 full bottle(720ml) per day  from past 2yrs


General examination-

Patient is conscious,coherent,cooperative and well oriented with time and place.

Moderately bulit and moderately nourished

no palor,icterus, clubbing, cynosis, lymphadenopathy, pedal edema

VITALS:

temperature: 98.6 f

pulse: 80bpm

respiratory rate: 18cpm

BP : 120/80 mmhg

spo2 98% @RA

SYSTEMIC EXAMINATION

CVS

S1 and S2 +, no murmurs.

R/S:

Bilateral air entry present. normal vesicular breath sounds heard

P/A:



Tenderness in epigastric region  present

CNS-

Cranial nerves,motor system and sensory system,reflexes-Normal 

Diagnosis: - Acute pancreatitis, Alcohol liver disease with AKI




















TREATMENT GIVEN 

NILL BY MOUTH

Ryle's Tube Catheterization

iv fluids 

INJ OPTINEURON 1AMP IN 100ML NS IV OD

INJ. ZOFER 4MG IV SO

INJ PANTOP 40MG IV BD

INJ . TREMADOL 1AMP IN 100ML NS IV SOS

tab UDILIV 300MG BD PO

INJ LORAZEPAM IM 2MG 9AM AND 4MG 9PM 

Acute pancreatitis Alcohol liver disease with AKI

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