Case of a 30 year old male with abdominal pain.
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This is the case of a 30 year old male , who is a painter by profession .
CHIEF COMPLAINT
The patient presented to the casualty with a complaint of abdominal pain since two days, vomiting since one day (10 episodes), and loose stools (3-4 episodes ).He has experienced similar episodes in the past .
HISTORY OF PRESENTING ILLNESS
The patient has a history of anemia when he was 6 or 7 years old , for which he received a blood transfusion .
He is an alcohol addict and consumed 90ml / day for the past 10 years . Three months ago, he stopped consuming alcohol because of GIT problems. On occasional consumption, he would experience severe abdominal pain and vomiting.
He has had 3 episodes of severe abdominal pain in the past three months , for which he was admitted to the hospital and treated with saline.
PERSONAL HISTORY
No history of DM, HTN, TB , Asthma and epilepsy
Appetite is normal
Diet - Non veg mixed diet. Unable to digest oily foodstuff.
Bowel movement- five to six episodes of loose stool.
Bladder movement- slight burning during micturition
Addicted to alcohol - 90ml /day since 10 years .
FAMILY HISTORY -
Mother -History of hypertension
VITALS-
Rt Lt
Reflexes- B ++ ++
T ++ ++
S ++ ++
K ++ ++
A ++ ++
PROVISIONAL DIAGNOSIS-
?Chronic pancreatitis
?Alcoholic gastritis
INVESTIGATION ORDERED-
USG ABDOMEN , ECG, Serum lipase, Amylase, electrolytes
TREATMENT
1. Inj Pantop 40 mg/IV/STAT
2. Inj Tramadol 1 AMPin 100 ml IV BD
3. Inj Zofer 4 mg/IV /STAT
4. Inj Optineuron 1 AMP in 100 ml NS/IV/OD
5. Inj Thiamine 1 AMP in 100 mlNS/IV/BD
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