c/o pain in theAbdomen since 3days

C/o vomitings since 3days (2-3 episodes /day)

patient was apparently alright 3 months back

Then  he developed similar complaints and was

diagnosed as Acute pancreatitis. Patient was advised for abstinence of alcohol.  

since 10 days patient started consuming Alcohol and he developed Pain in Abdomen since 3 days.

in the Left lumber region, Insidious onset, gradually progressive in nature.

Aggravated on sitting position, Relieved on lyingdown.

H/o vomitings since 3days (3episodes/day)  


Past history 

Pt had an h/o accident 8 yrs ago and had fractures on right leg and right arm for which he was treated in our hospital 




Rx: 

1. Inj. Tramadol in 100ml ns 
     IV/TID
2.IVF NS RL DNS @ 100ml/hr
3. Inj. PAN 40mg IV /OD
4. Inj. OPTINEURON 1amp in 100ml NS/IV/OD
5. Inj .ZOFER 4mg IV/OD
6. NBM TILL FURTHER ORDERS
7. GRBS MONITORING 


Psychiatry consultation i/v/o alcohol dependence 



Ophthalmology consultation i/v/o diabetic retinopathy 





Ortho opinion i/v/o of fracture on right leg











On 23/02/23

S:

Pain abdomen subsided 

Stools not passed


O:

On examination 

Pt is c/c/c

Bp : 120/70

Pr : 86bpm

Rr : 16cpm

Grbs: 144mg/dl

Temp : afebrile

CVS : s1s2 heard

RS: bae + nvbs

PA :soft and non tender

CNS: HMF +


A:

ACUTE PANCREATITIS WITH ALCOHOL LIVER DISEASE K/c/o DM TYPE 2 since 5 years


P: 


  1. Inj. Tramdol in 100 ml ns iv/sos
  2. IVF , NS RL DNS @ 100ml/hr
  3. INJ.PAN 40 mg IV/OD
  4. INJ. OPTINEURON 1 amp in 100 ml , NS/IV/OD
  5. INJ. ZOFER 4mg iv/OD
  6. ALLOW ORAL SOFT FOODS
  7. Tab. Metformin extended release 500 mg glimepiride and voglibose PO/BD
  8. GRBS MONITORING 

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