9/12/22
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Sanidha Singh
206
A 55 year old male patient auto driver by profession came to the OPD with complaints of vomiting and abdominal pain since yesterday.
CHIEF COMPLAINTS:
Vomiting since yesterday morning
Abdominal pain since yesterday evening (6 pm)
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic till yesterday morning then he started feeling nauseous and had 5 episodes of vomiting which was non projectile, bilious, with food content & non blood stained and later that evening around 6 pm he developed diffuse abdominal pain with h/o tenderness and no guarding
No h/o fever, trauma
PAST HISTORY:
H/O similar complaints 5 years ago.
N/K/C/O Diabetes, hypertension, tuberculosis, epilepsy.
FAMILY HISTORY:
No significant family history.
PERSONAL HISTORY:
Alcohol consumption since 15 years daily often takes a quarter before bed
Patient is smoker (bidhi) 6-7 / day
Diet- Mixed
Appetite- Reduced since 1 week
Sleep- Adequate
Bowel- Irregular ( 2-3 times in 5-6 days)
Bladder- Regular
GENERAL EXAMINATION:
Patient was conscious, coherent, non cooperative.
He is moderately built and moderately nourished.
No visible pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.
Vitals-
Temperature - 98.2
Pulse Rate - 74 BPM
Blood Pressure - 150/80 MM OF HG
Respiratory Rate - 20 CPM
SPO2 - 99 % at room air
GBRS- 121mg/dl
Systemic Examination -
Per Abdomen : Soft, Tenderness (+) in right and left lumbar, iliac and umbilical region, No Guarding.
CVS : S1 & S2 Heard , No murmurs.
RS : BAE (+), no crepitations, no wheeze.
CNS : NFD
INVESTIGATIONS:
Serum AMYLASE : 1867
Serum LIPASE: 1349
Alkaline phosphate: 197
Total bilirubin: 3.39
Direct bilirubin: 0.79
PROVISIONAL DIAGNOSIS:ACUTE PANCREATITIS
TREATMENT:
On 8/12/22
1) Inj. PAN 40 mg IV STAT
2) Inj. ZOFER 4 mg IV STAT
3) Inj. TRAMADOL IV in 100 ml NS over 20 mins
4) Inj. BUSCOPAN IV STAT
On 9/12/22
1) IV FLUIDS
2) NBM till further orders
3) Inj. TRAMADOL in 100 ml NS IV BD
4) Inj. PAN 40 mg IV OD
5) Inj. ZOFER 4 mg IV BD
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