A 33/M WITH C/O PAIN ABDOMEN AND VOMITINGS SINCE 2 DAYS
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Unit 6:
Case admitted in female ward on 6/2/2021.
Interns
K.Divya Rachana
K. Nikhil reddy
M. Swarna
B.Manivarma
Juveria
Dr. Manasa(pgy1)
Dr. Rashmitha(pgy2)
Dr. A. Vaishnavi (pgy2)
Dr. Sai Radha(pgy3)
Dr. Hareen (SR)
Dr. Arjun Kumar(asst.proff)
Dr.Praveen Naik( asst.proff)
A 33 YEAR OLD MALE PATIENT RESIDENT OF CHANDUR CAME TO THE HOSPITAL WITH COMPLAINTS OF PAIN ABDOMEN- AROUND UMBILICUS SINCE 3 DAYS.THROBBING TYPE OF PAIN AROUND UMBILICUS RADIATING TO RIGHT HYPOCHONDRIUM ASSOCIATED WITH VOMITINGS 8-10 EPISODES SINCE YESTERDAY.
NON PROJECTILE,NON BILIOUS,FOOD PARTICLES AS CONTENTS MINIMAL QUANTITY,NO BLOOD.
NOT ASSOCIATED WITH LOOSE STOOLS, CONSTIPATION,MUCUS/BLOOD IN STOOLS.
NOT ASSOCIATED WITH ABDOMINAL DISTENTION,PEDAL EDEMA, FACIAL PUFFINESS, CHEST PAIN, SHORTNESS OF BREATH, PALPATIONS.
HE REPORTS TO HAVE SLEEP DISTURBANCES,TREMORS, PALPITATIONS, HEADACHE, IRRITABILITY IF HE DOESN'T TAKE ALCOHOL OR TOBACCO.
LAST BINGE OF ALCOHOL 5 DAYS BACK
HE'S MARRIED
HE HAS DECREASED APPETITE, REGULAR BLADDER AND BOWEL MOVEMENTS
HE'S A CHRONIC ALCOHOLIC CONSUMING 750 ML EVERY DAY SINCE 15 YEARS
CHEWING TOBACCO SINCE 5 YEARS-3 PACKETS /DAY
ON EXAMINATION
PATIENTS IS CONSCIOUS COHERENT COOPERATIVE
NO PALLOR, ICTERUS,CYANOSIS, CLUBBING, KOILONYCHIA,PEDAL EDEMA, LYMPHADENOPATHY
TEMP-98.6°F
BP-130/100 MM OF HG
PR-90 BPM
SPO2-99 @ ROOM AIR
GRBS-120 MG/DL
CVS-S1 S2 HEARD
RS-NVBS
P/A-SCAPHOID, TENDERNESS AROUND UMBILICUS AND RIGHT HYPOCHONDRIAC REGION,NO ORGANOMEGALY
PROVISIONAL DIAGNOSIS-
ACUTE PANCREATITIS SECONDARY TO ALCOHOLISM
ALCOHOL DEPENDENCE AND TOBACCO DEPENDANCE SYNDROME
IV FLUIDS-0.9% NS,RL,DNS CONTINUOUS INFUSION @ 10) ML/HR
INJ PAN 40 MG IV BD
INJ THIAMINE 200 MG IN 100 ML NS IV TID
INJ ZOFER 4 MG IV SOS
INJ TRAMADOL 1 AMP IN 100 ML NS IV BD
INJ BUSCOPAN 2 CC IV SOS
