A 38 year male patient with pain in abdomen since 4 days

 A 38 years old male patient came to opd with cheif complaint of pain in abdomen since 4 days 

Patient was associated with nausea and vomiting since one week 

Patient is apparently Normal 4 years back .

He started consuming alochol(toddy)90ml once in three to four days 

History of present illness:two years back  patient has visited local hospital with complaint of pain in abdomen and he was admitted in hospital for alocholic liver diseases and got discharged 

 Patient again started consuming alcohol for three months and had a similar complaints and got admitted in hospital  

Ten days back patient has alcohol binge presented with pain in abdomen nausea and vomiting 

Has a mild pleural effusion one month back 

History of past illness:No Dm 

No HTN 

No EPILEPSY 

No asthama 

Personal history : 

 mixed diet 

Sleep adequate 

Apetite normal 

Bowel n bladder movements regular 

Micturition normal 

Habits: alcoholic and smoking 

Drug history: 

Patient was not allergic to any known drugs 

Family history: there is no history of similar complaints of family members 

General examination:

Patient is conscious coherent co-operative he is well oriented to time  place  and person 

Built: moderately built and well nourished

No pallor

No cyanosis 

No clubbing 

No lymphadenopathy 

No pedal edema 







Vitals: 

Temperature: Afebrile 

Pulse rate:70/min 

Respiratory rate:18/min 

Bp:110/80 

Spo2:98%

Systemic examination: 

Cvs:

Insepction :chest wall is bilaterally symetrical 

No precardial bulge 

No visible pulsations 

No engroaged veins 

Palpation:jvp normal 

Apex beat  felt in left 5th intercostal space in mid clavicular line 

Auscaltation:s1 s2 heard 

Respiratory system: 

Bilateral airway (+)

Position of trachea 

Normal  vesicular breath sounds heard 

No added sounds 

Per abdomen: 

Abdomen is soft and tender  

Mild ascities 

Minimal perispleenic loculated fluid present

No palpABle masses 

Herinial orifices normal 

No free fluid 

No bruits 

Liver 'not palpABle'

Spleen " not palpable' 

Bowel sounds heard 

CNS:

Patient is conscious alert  

Reflex are normal 

Speech is normal 

Provisional diagnosis:

Acute edematous  intestinal pancreatitis 

Treatment:

Inj Pan -40mg 

Inj zopher 

Inj thiamine

Ivs ns 500ml(100ml/hr)

Inj Tramadol 1 ampule in 100ml ns 

Monitor vital signs








 







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