47 year old male, lorry driver by occupation, came to hospital with C/O Pain Abdomen, vomitings and fever since 3 days.
HOPI:
Patient was apparently asymptomatic 3 days ago, and then he developed pain abdomen- intermittent, throbbing type of pain, initially in epigastric region and later progressed to diffuse type since 3 days, associated with vomitings-1 episode, non bilious, non projectile, food as the content.
- Pain Abdomen increases after food/water intake
- - Fever: low grade, intermittent, not associated with chills and rigors, burning micturition, headache, neck pains, relieved with medication.
- Had similar complaints in month of November, lasted for one day, subsided with medication.
- - Patient has not passed stools since 3 days
- Passing flatus +
- - Last alcohol intake 5 days
PAST HISTORY: Not a K/C/O HTN/DM/BA/Epilepsy
Past surgical history :
An implant was placed and removed in his left thigh due to femur fracture which happened because of bike vs bike accident 15 years ago
PERSONAL HISTORY:
Diet- mixed
Appetite- decreased since 3 days
Sleep- normal
Bowel and bladder movements- regular
Addictions-
Alcoholic since 10yrs, daily 180ml, last alcohol intake 5 days ago
Smoker-daily
FAMILY HISTORY:
Diabetes-2 brothers, on medication
Hypertension- mother , on medication
GENERAL EXAMINATION-
Pt C/C/C
No pallor/Icterus/cyanosis/clubbing/koilonychia/ generalised lymphadenopathy / pedal edema
Temp- afebrile
PR- 92 bpm
BP- 170/80 mmhg
Spo2-95% @RA
SYSTEMIC EXAMINATION -
CVS: S1 S2 +,No murmurs
RS: BAE+, NVBS heard
P/A: distended,tenderness+, diffuse guarding+, bowel sounds+
CNS: NFND
Investigations :
Chest x-ray pa view
DIAGNOSIS :
EROSIVE DUODENITIS 2° TO ALCOHOLISM WITH ALCOHOL DEPENDANCE SYNDROME , TOBACCO DEPENDENCE SYNDROME
WITH DENOVO DM
Rx:
1.NBM till further instructions
2.IVF NS,RL,DNS @100ml/hr
3.INJ.PANTOP 40 mg IV BD
4.INJ.ZOFER 4mg IV SOS
5.INJ.TRAMADOL 1amp in 100ml NS IV TID
6.INJ.THIAMINE 1amp in 100ml NS IV TID
7.GRBS 4th hourly
8.I/O Charting
9.Monitor vitals 4th hrly
21/1/2022
Psychiatry referral
Gastro referral :
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