26 Year Male with Recurrent Acute Pancreatitis

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Patient is a 26 year old male, car driver by occupation came to the casualty at 1am with complaints of : 

Cheif complaints:

  •Pain abdomen since 1 day

  •4-5 episodes of vomitings

History of presenting illness

Patient was aymptomatic 6 months back. Then he developed pain abdomen not associated with vomitings not admitted to PE hospital. Subsided on taking medication (augmentin, Tramadol) 

Now today at 1am the patient developed pain abdomen sudden in onset and associated with 2 episodes of vomitings which were bilious. 

Had similar complaints in the past around 12 years back. 

History of past illness

N/K/C/O DM,HTN,TB,thyroid disorders,epilepsy

Personal History

Married 

Car driver by occupation 

Diet: mixed 

Appetite: lost

Bowel bladder moments: regular

Addictions : Chronic alcoholic, stopped 1 month back. 

Family history

Not significant

On examination

Pt is conscious,coherent and cooperative well oriented to time,place,person 

No signs of pallor,icterus,clubbing,cyanosis,lymphadenopathy,pedal oedema 

Vitals

Temp:98.6°F

PR: 82

Rr: 16/ min

Bp:120/70 mm Hg. 

Spo2: 98%

GRBS:102mg%

Systemic examination

CVS: S1,S2 heard, no murmurs heard 

Resp: BAE +

CNS :NAD 

Abdomen: 

Soft, mild tenderness in epigastrium & left hypochondrium no guarding, non ? Bs +

Investigations:

HCV, HIV , HbsAg : negative

Blood Urea : 14mg/dl

Sr. Creatinine: 0.8 mg/dl

CRP : 2.4 mg/dl 

FBS: 86 mg/dl

Blood group : A+ 

Hemogram 

Sr. Electrolytes 

Provisional diagnosis: Acute Pancreatitis

Treatment History 

Day 1 

NBM TIL FURTHER ORDERS

• INJ TRAMADOL IN 100ML NS TID 

• INJ PAN 40 mg OP IV

•INJ ZOFER 4mg IV 

• INJ CIPROFLOXACIN 500mg IV BD 

• IV fluids NS /RL / DMS (@75 ml/min)

 GRBS -every 6th hourly 

BP every 4th hourly 

Day 2 

• INJ TRAMADOL 1amp IN 100ML NS TID 

• INJ PAN 40 mg OP IV

•INJ ZOFER 4mg IV 

• INJ CIPROFLOXACIN 500mg IV BD 

• IV fluids NS /RL / DMS (@75 ml/min)

 GRBS -every 6th hourly 

BP every 4th hourly 

Day 3 

• INJ TRAMADOL IN 100ML NS TID 

• INJ PAN 40 mg OP IV

•INJ ZOFER 4mg IV 

• INJ CIPROFLOXACIN 500mg IV BD 

• IV fluids NS /RL / DMS (@75 ml/min)

 GRBS -every 6th hourly 

BP every 4th hourly 

Patient discharged on day 4