Case of a 19 years old male with abdominal pain.
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This is the case of a 19 years old boy, who is a student and resident of Nalgonda.
CHIEF COMPLAINTS
The patient presented to the casualty with the chief complaints of loose stools and continuous abdominal pain from 3 days and two episodes of vomiting, the day before admission.
HISTORY OF PRESENTING ILLNESS
The patient was apparently asymptomatic 3 days ago. He had attended a function where he consumed very oily food. From that day he had 5-6 episodes of loose stools every day. Yesterday, the patient went to another hospital where he was diagnosed with acute appendicitis and was told that he would require surgery.
One day ago, the patient had two episodes of vomiting (green in colour- bilious, non-projectile). He had an episode of fever (102 degrees F), one day ago.
The patient presented to the casualty today with complaints of loose stools (5-6 episodes a day) and continuous abdominal pain (increased during defecation).
PAST HISTORY
The patient is not a known case of DM, HTN, Asthma, Epilepsy or TB.
FAMILY HISTORY
No relevant family history.
PERSONAL HISTORY
Diet- normal
Sleep- adequate
Smoking - no
Alcohol - no
Other addictions- the patient is a regular consumer of toddy. He has been consuming toddy from a very young age. He consumes little every day. He consumed 1 glass of toddy 4 days ago.
VITALS
Patient is conscious, coherent and oriented to time and place.
PR- 89 bpm
BP- 130/80 mm Hg
Temperature - afebrile
SpO2- 99%
GRBS- 115 mg/dl
GENERAL EXAMINATION
Pallor- absent
Icterus- absent
Clubbing- absent
Cyanosis- absent
Lymphoedema- absent
Edema- absent
INVESTIGATIONS
CBP
RFT
LFT
USG
ECG
Inj PAN 40 mg IV/STAT
Inj ZOFER 4 mg IV/STAT
Inj METRONIDAZOLE 100 ml IV/STAT
IVF- 10 NS @70 ml/hr
10 RL @70ml/hr
Tab SPOROLAC 2 tab STAT
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