55 year old male with acute pancreatitis

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CHIEF COMPLAINT:

58yr old male patient ,he's a cook by occupation came to casuality with a C/O pain in upper abdomen, with vomitings since yesterday morning.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic upto yesterday 

Later he developed pain in upper abdomen Which was sudden in onset Progressive and non radiating and not relieved on medication.

H/O Vomiting since today mrng 5-6 episodes,water as content,non projective ,non bilious

No H/O fever, constipation, loose stools

Patient started drinking alcohol 15yrs back ,he consumes 90ml daily at night. 

HISTORY OF PAST ILLNESS:

N/K/C/O HTN,DM,CAD,TB,epilepsy,Asthama

No past surgical history 

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

-No clubbing of fingers 

VITALS:

Temperature-afebrile

Pulse rate -90 bpm

Respiration rate -16cpm

Bp-110/80 mm Hg

Spo -98%

SYSTEMIC EXAMINATION:

▪️CVS

S1 & S2 sounds are heard

▪️ RESPIRATORY SYSTEM

-BAE present

INVESTIGATIONS 

Serum creatinine -0.9

Blood urea- 20mg/dl

Serum electrolytes:

Sodium-137

Potassium-4

Lipase-29

Amylase- 84

DIAGNOSIS:

ACUTE PANCREATITIS

TREATMENT:

Inj PAN 40mg IV /OD

Inj BUSCO PAN IM