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
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