31 year old male with acute pancreatitis

CHIEF COMPLAINT:
31 yr old male patient ,farmer by occupation came to casuality with a chief complaint of abdominal pain since 5 days

HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 10 yr back then started drinking alcohol with friends occasionally which then gradually turned into a habit. Since then patient used to consume 90-180mg/ 7 days a week for approximately for 6-7 yrs till 20 days back.
15 days back patient complained of Abdominal pain gradually Progressive, Aggrevated after food consumption.Having similar complaints of Episodes and abdominal pain for every 6months /1 year over the last 6 years.patient went to a local hospital where he was diagnosed with Chronic pancreatitis.

HISTORY OF PAST ILLNESS:
No history of HTN,DM,CAD,TB,epilepsy

PERSONAL HISTORY:
Appetite-normal
Diet-mixed
Bowel and bladder Movement-Regular
No allergies 
Alcoholic regularly

GENERAL EXAMINATION:
patient is Conscious,coherent and cooperative 

-No pallor

-No icterus

-No lymphadenopathy

-No cyanosis

VITALS:
Temperature-afebrile
Pulse rate -80 bpm
Respiration rate -18cpm
Bp-130/60 mm Hg
Spo -98%

SYSTEMIC EXAMINATION:
▪️CVS

S1 & S2 sounds are heard

▪️ RESPIRATORY SYSTEM

-BAE present

INVESTIGATIONS:
Serum creatinine-0.6mg/dl
Blood urea- 12mg/dl
Serum electrolytes:
Sodium-142
Potassium-3.6
Lipase-102
Amylase-256
PROVISIONAL DIAGNOSIS:
Acute on chronic pancreatitis

TREATMENT:
Inj• TRAMADOL 50 mg in 100ml IV/SOS
Inj• PAN 40 IV/OD
Inj• ZOFER 4mg IV /SOS
Inj• THIAMINE 1 Amp in 100 ml IV /BD

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