65 y old male

 



65 y old male resident of kethepally farmer by occupation came to opd with chief complaints of stomach pain since 4 days.

Chief complaints :

- stomach pain since 4 days

- fever

- nausea,vomitings


History of present illness:

Patient was apparently asymptomatic 7 days back 

Then he developed abdominal pain for which he visited local RMP and got injections 

And after 2 days he again got symptoms 

Then he developed abdominal pain, in epigasttic region and right and left hypochondrium regions.

Burning type pain is present radiating to lumbar region on back.

Pain aggravated on taking food and relieved on taking medication.

History of fever is present 

Nausea is present 

2-3 episodes of vomitings which are non projectile non bilious and contained food particles 

Past history:

History of similar complaints 2 months back for which he has visited hospital and diagnosed as having gall bladder stone .

Not a known case of diabetes,hypertension,asthma,cardiovascular diseases.

History of surgery for right sided inguinal hernia 20 years back.


Personal history:

Mixed diet

Appetite normal

Normal bowel and bladder movements

Sleep is adequate 

Addictions:

Daily consumption of toddy for 50 years 

Alcohol Consumption daily for 40 years occasionally since 10 years.

Smoking for 50 years and stopped a year back


Daily routine:

He wakes up at 6 am gets ready and has his tea and breakfast (rice) by 9 am and leaves to work . He is shepherd now. He eats lunch at 2 pm and comes home by 7 pm and has his dinner and sleeps by 9 pm

Family history : not significant 

GENERAL EXAMINATION:

Patient is conscious,coherent,cooperative

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema.

Temp:97.8F

Bp:120/80 mm Hg

Rr:18 cpm

Pr:81 bpm


SYSTEMIC EXAMINATION:

PER ABDOMEN 

Inspection:

- Abdomen is obese

- Umbilicus is central

- All quadrants move equally with respiration.

- No scars, sinuses, engorged veins


Palpation:

- soft

- Tenderness present over left hypochondrium, epigastric region.

- No local rise in temperature 

- All the inspectory findings are confirmed


Percussion:

Resonant 


Auscultation: 

Bowel sounds heard.


Chest X ray pa view 

Errect abdomen X ray





Usg abdomen



CNS: nfnd

CVS: S1 S2 heard,No murmurs 

RS: blae+ , NVBS heard


INVESTIGATIONS:

24/6/23













25/6/23









26/6/23


DIAGNOSIS:

Pain abdomen secondary to ? Alcoholic gastritis? Acute pancreatitis 


TREATMENT:

- Nbm till further orders

-Iv fluids: Ns, RL, DNS @ 100ml/hr

- inj. Thaimine 200mg iv/bd

- inj. Tramadol 1 amp in 100ml ns/iv/ sos

- inj. Pan 40 mg/iv/od

- inj zofer 4 mg iv/od

- inj. Buscapan im/sos





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