32 year old male complaints of pain abdomen

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32 year old male came to the casualty with clo Pain abdomen in epigastim ,left hypochondrium Since 1 day.
C/o vomiting since 1day
(non-billious,non projectile) 2episodes ,
containing food-particles
Passing flatus, constipation since 1day 
morning
Loss of appetite+
No c/o fever


HISTORY OF PAST ILLNESS

not a K/c/o DM HITN, epilepsy,asthma, CVA,CAD .

PERSONAL HISTORY-
Loss of appetite+,takes mixed diet ,bowel and bladder movements were regular .
H/o alcohol consumption(beer) since 5yrs(2times a day) stopped 1 month back. 

ON EXAMINATION-
Patient  is conscious ,coherent ,co-operative 
Temp-98f
PR-90BPM
RR-20CPM
BP-100/70mmhg
GRBS-266MG/DL
Spo2-98@RA
CVS-S1S2+
RS-BAE+,NVBS
P/A-SOFT,NON TENDER,B/S+
CNS-NAD
INVESTIGATIONS 
HIV,HCV,HBsAg -negative
Hemogram on 30/10/2021


DIAGNOSIS-  
ACUTE PANCTREATITIS SECONDARY TO ALCOHOL

TREATMENT-

1)IVF- NS,RL-150ML/HR
2)INJ.PAN.40MG/IV/BD
3)INJ. THIAMINE 200MG IN 100ML NS /IV/BD
4)INJ.OPTINEURON 1AMP IN 100ML NS/IV/OD
5)INJ.TRAMADOL 1AMP IN 100 ML NS/IV / BD
6)INJ .ZOFER 4MG /IV/BD
7)strict I/O monitoring 
8)BP,PR,SPO2 Monitoring 4th helt
9)GRBS monitoring 6hrly
10)inform sos
 SOAP NOTES DAY-2

S: No fresh complaints
Pain abdomen decreased

O:
PR: 82bpm
Bp: 130/80mmhg
Temp: 99F
RR:18cpm
Cvs:s1,s2heard
Rs:BAE+
CNS:NFD 
GRBS :157 mg/dl
A:
Acute pancreatitis secondary to alcohol with denovo diabetes

P:
1)IVF :NS and RL 100 ml /hr
2)INJ pantop 40 mg IV BD
3)INJ.THIAMINE 200MG IN 100ML NS IV/OD (OVER 30MIN)
4)INJ.TRAMADOL 1AMP IN 100ML NS IV/SOS
5)INJ.ZOFER 4MG IV/BD
6)INJ.HAI S/C,acc to GRBS
7)BP,TEMP MONITORING

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