50 YR OLD MALE MESTRI BY OCCUPATION CAME WITH C/O PAIN ABDOMEN SINCE 1 DAY a/w NAUSEA
- PAIN ABDOMEN :- SUDDEN IN ONSET , EPIGASTRIC REGION , CONTINUOUS , SQUEEZING , NON RADIATING , AGGREVATING AFTER EATING FOOD , RELIEVING AFTER TAKING MEDICATION AND LEANING FORWARD
- H/O ALCOHOL INTAKE
- CHRONIC ALCOHOLIC SINCE 6-7 YEARS
HOPI:-
PATIENT WAS APPARENTLY ASSYMPTOMATIC 6 YEARS BACK DUE TO LOSS OF HIS WIFE HE STARTED DRINKING ALCOHOL ( WHISKEY - 90-180ML) / EVERY DAY . USED TO DO HIS ROUTINE WORK .
- 2 YEARS BACK PATIENT C/O TINGLING OF B/L UL AND LL, TAKEN TO LOCAL HOSPITAL , INCIDENTALLY FOUND TO HAVE RAISED CREATININE (2.4MG/DL) AND SINCE THEN WAS ON MEDICATION AND STOPPED TAKING SINCE 1 YEAR
SINCE YESTERDAY PATIENT COMPLAINTS OF SQUEEZING TYPE OF ABDOMINAL PAIN ( EPIGASTRIC REGION), SUDDEN IN ONSET , AGGREVATED ON TAKING LIQUIDS , RELIEVING ON BENDING FORWARD , AGGREVATED ON SUPINE POSITION RELIEVING WITH PAIN MEDICATION
- C/O NAUSEA , VOMITINGS 1 EPISODE
- C/O BURNING SENSATION IN EPIGASTRIC REGION
- C/O CHEST HEAVINESS PRESENT
- NO H/O BURNING MICTURITION
- PASSING FLATUS
PAST HISTORY:-
- NO SIMILAR COMPLAINTS IN THE PAST
- NO H/O DM, HTN , EPILEPSY , ASTHMA , CAD
TREATMENT HISTORY:-
- NOT SIGNIFICANT
PERSONAL HISTORY:-
APPETITE :- NORMAL
DIET - MIXED
BOWEL AND BLADDER :- NORMAL
ADDICTIONS:-
- CHRONIC ALCOHOLIC SINCE 6-7 YEARS ( 90ML / DAY)
- NO SMOKING HISTORY
FAMILY HISTORY:-
NOT SIGNIFICANT
O/E:-
PT IS CONSCIOUS, COHERENT , COOPERATIVE , WELL ORIENTED TO TIME , PLACE, PERSON
- NO PALLOR, CLUBBING , CYANOSIS , ICTERUS ,
VITALS:-
TEMP:- 98.4
PR:- 84/MIN
RR:- 20/ MIN
BP:- 150/90
SPO2:- 96% RA
CVS:- S1S2 HEARD
RS:- BAE PRESENT , NVBS
P/A :- SOFT , NON TENDER
- GREY TURNER :- NEGATIVE
- CULLENS:- NEGATIVE
CNS:- INTACT
Dx:-
ACUTE PAIN ABDOMEN SEC TO ACUTE PANCREATITS
INVESTIGATIONS:-
HEMOGRAM:-
HB:- 17.3
TC:- 15.300
N/L/E/M:- 84/10/02/04
RBC:- 6 millions/cumm
PLT COUNT :- 2.2 lakhs
NORMOCYTIC NORMOCHROMIC WITH NEUTROPHILIC LEUKOCYTOSIS
RBS :- 140mg/dl
LFT:-
Tb:- 1.50
Db:- 0.70
AST:- 40
ALT:- 44
ALP:- 174
TP:- 7
ALBUMIN:- 4 gm/dl
A/G :- 1.38
PT:- 16 sec
INR:- 1.11
SERUM CREATININE :- 2.1 mg/dl
Electrolytes :-
Sodium:- 140 meq/L
Potassium:- 2.9 meq/L
Chloride :- 90 meq/L
CUE :-
COLOUR :- PALE YELLOW
REACTION:- ACIDIC
SP GRAVITY:- 1.010
PUS CELLS:- 3-6
EPITHELIAL CELLS:- 2-4
RBCs:- NIL
ALBUMIN:- NIL
SUGARS:- NIL
BILE SALTS :- NIL
BILE PIGMENTS - NIL
SERUM AMYLASE :- 71 IU/L
SERUM LIPASE :- 28 IU/L
CHEST X RAY
ECG:-
Impression:-
1) Grade 1 fatty liver with mild hepatomegaly
2) left grade 1 RPD with simple cortical cysts
3) Increased echogenicity of right tendency with simple renal cortical cysts
Rx:-
INJ CEFTRIAXONE 1g IV/BD
NBM TILL FURTHER ORDERS
IVF - NS AND RL @125 ML/HR
INJ PAN 40mg IV/OD
INJ ZOFER 4mg IV/TID
INJ THIAMINE 1amp in 100ml NS IV / TID
STRICT I/O CHARTING
INJ TRAMADOL 50mg in 10ml NS SLOW IV TID
MONITOR VITALS AND INFORM SOS
ABDOMINAL GIRTH MONITORING EVERY 4th HRLY
BP/PR/ RR / SPO2 CHARTING
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