Case history- 7

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her /guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input 

48 YEAR OLD MALE WITH ACUTE GASTRITIS

A 48 yr old male farmer by occupation came to the casualty with a chief complaint of abdomen pain since 10 days and complaints of severe vomitings since 1 day 

HISTORY OF PRESENT ILLNESS:

Patient was apparantly asymptomatic 10 yrs ago,  and then diagnosed with DM , Hypertension 10 yrs ago, and started regular medication since then.

 Complaints of abdominal pain since 10 days which was aggrevated since 3 days .

Complaints of vomitings since 1 day ie., 10-15 episodes which got subsided now 

No complaints  of fever , loose stools, cough, Shortness of Breath, burning micturition.

PAST HISTORY:

Known case of DM since 10 years .

Known case'of Hypertension since 10 yrs .

No history of CAD , epilepsy , asthma, TB, Lymphadenopathy,edema.

 

PERSONAL HISTORY:-

Diet-mixed 

Appetite- normal 

Bowel and bladder- regular 

Alcoholic since 10 yrs (occasionally) 

GENERAL EXAMINATION:

No pallor

No icterus

No cyanosis

No clubbing

No Lymphadenopathy

No edema

OBESE ABDOMEN:

VITALS:

Temperature- 98.2F

PR- 72 bpm

RR- 20 cpm

BP- 170/110 mmHg

GRBS- 180mg%

SYSTEMIC EXAMINATION:

CVS-S1,S2 heard

RS-BAE present,NVBS heard

P/A-tenderness present in epigastric region. 

CNS-No FND

PROVISIONAL DIAGNOSIS:

ACUTE GASTRITIS 

Known case of  ACUTE ON CHRONIC PANCREATITIS 

Known case of  HTN,DM

TREATMENT:

INJ.PAN 40 MG IV BD

SYP.SUCRALFATE 10 ML PO BD

INJ.ZOFER 4 MG IV TID

INJ.THIAMINE 100 MG IN 100 ML NS IV OD

INJ.TRAMADOL 1 AMP  IN 100 ML NS IV SOS

T.GLIMI M1 500 MG PO OD

T.AMLONG 5 MG PO OD