A28 YEAR OLD MALE WITH ACUTE PANCREATITIS.

Name: Y .Navya Sahithi Reddy
Roll no: 146
Date : 30-03-2022.

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A 28 Year old male resident of hyderabad and tailor by occupation came to the opd with 
Cheif complaints of:
1.pain in the abdomen 3 days back in the epigastric region.
2.vomitings since 2 days.

HOPI :
Patient was asymptomatic 3 days ago later  he developed pain in the abdomen which colicky type of pain ,incidious in onset gradually progressive  and it is radiating backwards and aggrevated after taking meals.
Some relief on leaning forward.
Vomtings:
There were 2 episodes of vomitings since 2 days which is non prohectile,non bilious,food particles as content.
There was no h/o loose stools,constipation,fever.

PAST HISTORY:
There is no history of trauma.
Patient had cholelithiasis 8 years ago diagnosed by endoscopically.
There is no history of DM, HTN,Asthma,TB.

TREATMENT HISTORY:
There is history of endscopic surgery for cholelithiasis.

PERSONAL HISTORY:
DIET: MIXED
SLEEP: DISTURBED SINCE 3 DAYS DUE TO PAIN
APPETITIE: ADEQUATE
BOWEL AND BLADDER MOVEMENTS: REGULAR.
NO ADDICTIONS.

FAMILY HISTORY:
No one in his family have similar complaints .

GENERAL EXAMINATION:
Patient was conscious ,coherent cooperative,moderately built.
There is no pallor,cyanosis,lympadenopathy,clubbing,icterus,edema.
Vitals:
Temp: afebrile
Pulse rate-127/min
Redpiratory rate- 16/min
BP: 110/90mm of hg
Spo2:90%
GRBS:109 mg %


Systemic examination:

CVS: S1 and S2 are heard.
No murmurs and thrills.

Respiratory examination:
There is no dysnoea,wheeze.
Breath sounds are vesicular.

Abdominal examination:

Inspection:
Shape of the abdomen:scaphoid
No scars and sinuses.
No engorged veins.

Palpation:
Tenderness is present in epigastric region.
Liver and spleen are not palpable.
Bowel sounds are sluggish.


CNS:
NAD

Investigations:
Serum amylase:528IU/ lt.
Serum lipase:124IU/lt.
Blood urea:50mg/dl.
USG: Tiny focal caliculi.





ECG:

provisional diagnosis:

Acute pancreatitis secondary to gall stones.

Treatment:
Inj.Tramadol
100 ml of ringer lactate-IV.














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