22 year old male with the complainants of
22yr old with c/o pain abdomen
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Hall ticket no. 1701006129
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DOA: 7/6/2022
A 22yr old male pt. painter by occupation resident of nalgonda came with
Cheif complaints:
Pain abdomen since 4 days.
HOPI:
Pt. Has started consuming alcohol 4 yrs back due to peer pressure , intially taking one peg per day which has increased to 90ml morning and evening i. e twice daily. He has stopped consuming alcohol 3 months back as advised by the doctor.
Pt. Has history of smoking since 2 yrs . He has been smoking beedies 5 per day till date.
Pt was apparently asymptomatic 3 months back then he developed abdominal pain which was dragging in character for which he was admitted in near by hospital in nalgonda . He was diagnosed with acute pancreatitis and was treated inadequately and was advised to stop consumption of alcohol.
Since then pt has stopped consuming alcohol and has been experiencing alcohol withdrawal symptoms like getting angry , agitation , irritability , craving to consume alcohol, tremors . Pt had consumed alcohol 4 days back due to family problems.
In veiw of this symptoms pt.has been brought to psychiatry OPD for deaddiction. He was referred to medicine OPD in veiw of pain abdomen.
Pain was , insidious in onset , started after consuming of alcohol in epigastrium and left hypochondrium which was relieved on bending forward and lying down , aggrevated on eating food and standing straight.
No h/o fever , nausea , vomiting.
Past history:
H/o similar complaint in past 3 months back.
No other co morbid conditions
No h/o previous medical surgical history.
Family history :
Not significant
Personal history
Diet : mixed
Appetite : normal
Bowel bladder: regular
Sleep: inadequate
General examination:
Pt was concious coherent and cooperative
Thin built and moderately nourished
Pallor - present
No icterus,cyanosis , clubbing,lymphadenopathy, edema
Vitals at the Time of admission
Temperature- afebrile
Pulse rate-94bpm
Blood pressure-120/80mmHg
Respiratory rate- 16cpm
Systemic examination:
Abdominal examination:
Inspection:
Shape of the abdomen- flat
Umbilicus is central
No visible scars,pulsations, peristalsis, engorged veins
Palpation:
All the inspectory findings are confirmed.
Tenderness present over the epigastrium region
No organomegaly
Percussion
No free fluid
Ascultation:
Bowel sounds heard
Other systems:
Respiratory:
b/l air entry present , no added breath sound
CVS :
S1 S2 heard , no added murmurs
CNS :
Higher function intact
No motory and sensory deficit.
Cranial nerves normal .
Investigations
Complete blood picture
Complete urine examination
RFT
USG abdomen
Serum amylase
Serum lipase
Diagnosis:
Pseudocyst of pancreas secondary to unresolved acute pancreatitis.
Treatment:
Nil per oral
IV fluids Ringer lactate ,Normal saline 100 ml per hour
Inj. Tramadol100mg in 100ml NS IV BD
Inj.pantop 40 mg IV OD
Inj. Optineurin 1 ampoule in 100ml NS IV OD
Psychiatry medication
Tab . Lorazepam 2mg BD
Tab . Benzothiamine100mg OD
