32 year old male

Patient was apparently asymptomatic 1 day ago.32 year old male lorry driver by occupation came to casualty with chief complaints of pain in abdomen since one day.
Patient had alcohol intake today morning (14/09/21), and had food in the afternoon.
 Then he developed pain in abdomen at umbilical region, throbbing type, non radiating, aggravated after food intake, not associated with nausea, vomiting , constipation and loose stools, No
History of fever and burning micturition.

Not a known case of hypertension diabetes epilepsy tuberculosis asthma.

O/E:
vitals: temperature AFEBRILE, pulse rate 88 BPM, respiratory rate 16 CPM , BP 130/80 mm Hg, spo2 98% at Room air.
CVS : S1 S2 heard
RS: BAE+ NVBS +
PA: obese abdomen, tenderness in gastric and hypochondrial region, bowel sounds present.

Provisional diagnosis:
Acute pancreatitis? Secondary to alcohol dependence

INVESTIGATIONS : 

HEMOGRAM :
HB : 14.3 GM/ DL
TLC : 11,400 CELLS/ CUMM
RBC : 4.34 MILLION/ CUMM
PCF : 2.05
PCV : 40.1 VOL %

RFT:
 UREA : 18 MG/ DL
CREATINE : 1.0 MG/ DL
SODIUM : 141 mEq/L
POTASSIUM : 3.5 mEq/L
CHLORINE : 98 mEq/L

SERUM . AMYLASE : 42
SERUM .LIPASE : 24
 TREATMENT GIVEN :
1) IVF 0.9 % NS AND IVF RL @ 50 ML/ HR
2) ORAL FLUIDS 
3) INJ AUGMENTIN 1.2 G/ IV / BD
4) INJ PAN 40 MG / IV/OD
5) SYP . AMBROXOL 10 ML / PO/TID
6) INJ HAI S/C / TID
7) INJ OPTINEURON 1 AMP IN 100 ML NS / IV/OD
8) TAB PCM 650 MG / PO/TID
9) INJ NEOMOL 1G/IV/SOS 
10) NEB BUDECORT,MUCOMIST @ 4 HOURLY 
11) CREMAFFIN PLUS 10 ML / PO/ H/S



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