A 50 year old male with acute abdomen

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CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDER

Chief complaints

  A 50 year old male resident of nalgonda presented to opd on 2/1/23 morning with chief complaints of pain Abdomen since 6hours. 

History of present illness:

 Patient was apparently asymptomatic 6hours then he developed pain Abdomen which was sudden in onset at 12am on 2/1/23 and gradually progressive. Pain was diffuse but more in umbilical and left lumbar region. It was colicky type and non radiating but continuous in nature. History of alcohol intake present. There are no aggravating and relieving factors. No h/o fever, nausea, vomiting and loose stools. 

Past history : 

Similar complaints in the past 2 years back  and was diagnosed as Acute pancreatitis. 

Patient is know case of diabetes since 2 years and is on medication. Patient is not a know case of Hypertension, Asthma, tuberculosis, thyroid abnormalities and epilepsy. 

Family history: not significant 

Personal history: 

Daily routine : He wakes up at 8am and does his daily routine and does not go for work and takes 3 meals daily. He drinks alcohol and smokes intermittently through the day and sleeps by 10 pm.

Diet: mixed

Appetite: normal

Sleep : disturbed since 2 days

Bowel and bladder movements: regular 

Addictions: Chronic alcoholic since 30 years and takes 180ml per day on an average. Cigarette (tobacco) 2-3 packs daily since 30 years.  

Allergies : none 

 General physical examination: 

Patient is conscious, coherent and cooperative.  Moderately built and nourished. 

Pallor : absent 

Icterus : absent 

Cyanosis : absent 

Clubbing: present

Lymphadenopathy: absent 

Edema : absent 

Vitals: 

Blood pressure: 150/100 mmHg 

Pulse rate: 65bpm

Respiratory rate: 20cpm

Temperature: afebrile 

Systemic  examination: 

Abdomen: 

Inspection: Abdomen is obese, Umbilicus is central and inverted. All quadrants of Abdomen are moving accordingly with respiration. No visible scars sinuses or engorged veins. 

Palpation: All inspectory findings are confirmed. Abdomen is soft and tenderness is present in the umbilical region and left lumbar region. No guarding, no rigidity, no Hepatosplemomegaly and hernial orifices are free . 

Percussion: no shifting dullness.

Auscultation: Bowel sounds present. 

CVS: S1 S2 present , no murmurs heard 

CNS: No focal neurological deficits. 

Respiratory system : Bilateral air entry present. Normal vesicular breath sounds heard. 

Provisional diagnosis: Acute on chronic pancreatitis secondary to alcohol intake 

Investigations: 

HAEMOGRAM: 

Serum amylase: 

Serum lipase: 

Random blood glucose : 

Serum creatinine: 

liver function tests: 

complete urine examination: 

USG : 

2D ECHO: 

 CT  SCAN: 

 

Treatment: 

-NBM 

-  IV fluids : NS and RL ( 100ml/hr) 

-Inj pantop 40mg IV OD 

-Inj Thiamine 200mg in 100ml NS iv tid 

- Inj HAI s/c tid premeal. 

- BP, PR, RR, temperature monitoring and charting 4th hourly.