Gm case (45 yr male)
GENERAL MEDICINE
17-11-22
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DATE OF ADMISSION: 16-11-22
A 45 year old male laborer by occupation came to opd with
CHIEF COMPLAINTS OF:
. Severe pain in abdomen
HOPI:
. The patient was apparently asymptomatic 1 month back and developed severe pain abdomen which was sudden in onset for which he went to rmp hospital and pain subsided after taking medication for 2 days
. Again he developed sudden pain in abdomen 1 week back in the epigastric and right hypochondriac region radiating to backside dragging type of pain, no aggrevating or relieving factors
. Associated with 2 episodes of vomiting
. No h/o fever, burning micturition, chest pain , breathlessness
PAST ILLNESS:
. Known case of HTN from 3 years ( 40 mg telmisartan)
but he doesn't take it regularly
. Not k/c/o diabetes, TB , asthma , epilepsy, CAD, CVA
PERSONAL HISTORY:
diet- mixed
Appetite- decreased appetite since 1 years
Sleep- normal
Bowel and bladder movements- regular
Addictions- regular alcohol consumption since 30years
SURGICAL HISTORY
. No surgical history
FAMILY HISTORY
.No significant Family history
.no known allergic history
PHYSICAL EXAMINATION
General examination:
. The patient is conscious, coherent, cooperative
. Well nourished and Moderately built
. No pallor, icterus, cyanosis, clubbing, lymphadenopathy, Pedal edema
VITAL SIGNS: on day of admission
Pulse rate - 82 bpm
Respiratory rate - 16 cpm
Blood pressure - 130/80 mmHg
Temperature - afebrile
SYSTEMIC EXAMINATION :
Systemic examination :
CVS : S1 and S2 heart sounds hear
NO murmurs and thrill
RESPIRATORY SYSTEM : Bilateral air entry present
position of trachea - central
Vesicular breathsounds heard
CNS :
▪︎NAD and HMF intact
PER ABDOMEN
Inspection- Umbilicus is central and inverted
•No engorged veins, scars seen
Palpation- all inspectory findings are normal
. Tenderness felt in epigastric and right hypochondriac region and right lumbar region
Percussion:
•No free fluid
CLINICAL IMAGES
PROVISIONAL DIAGNOSIS: Acute pancreatitis
INVESTIGATIONS
Hemogram
Complete Urine examination
Liver function test
RFT
Lipase
Amylase
HBsAg- ELISA
Anti Hcv Antibodies
Hiv 1 and 2 ELISA
Anti HCV antibiodies- rapid
TREATMENT:
. IVF - NS, LS
. Inj tramadol 100mg in 100ml NS over 1hr
. Tab 40mg pantop
. Tab telmisartan 40mg
. Inj thiamine 100mg in 100 ml iv/ BD
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