A 55 year old male with Acute Pancreatitis

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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