General Medicine Case

 August 23, 2021

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Date of admission : 16/08/2021

A 45 year old male , who is an industrial worker came to the OPD with chief complaints of - 

• Pain in upper abdomen

• Pains gets seviour on alcohol consumption

• Nauseous

HISTORY OF PRESENT ILLNESS:

~ Patient was apparently asymptomatic 5 years back then. 

~ 7 days back he developed upper  abdominal pain.

~ Also suffering from headache .

~ Throbbing type of pain.

~ Insidious in onset which gradually progressed.

~ Followed by constipation.

~ While diagnosis he was also observed to be suffering from a painful gait (due to weight being barred by left leg).

~No swelling of abdomen.

~History of Weight loss.

 ~Excessive sweating.

PAST HISTORY:

•5 years back he was diagnosed with same abdominal pain due to alcohol consumption.

• No history of trauma.

•No history of epilepsy

• Known patient of diabetes mellitus from 2yrs

• Has being prescribed insulin since 6months 

• History of pulmonary koch 2yrs back

• No hypertension-CKD

•No asthma 

•No history of surgeries 

•No history of previous radiation exposure 

PERSONAL HISTORY 

•Diet:Mixed diet 

•Appetite: normal 

•Sleep: Inadequate

•Bowel and bladder movements: constipated

•Addictions: Alcoholic since 15years

FAMILY HISTORY:

•No history of similar complaints in the family members 

TREATMENT HISTORY

•No history of drug allergy 

GENERAL EXAMINATION 

•Patient is coherent co-operative ,well oriented, normal built, abnormal gait and malnourished.

• No pallor 

•No icterus 

• No cyanosis 

•No lymphadenopathy 

•No pedal edema 

VITALS 

•Temperature:98.5f 

•Blood pressure:100/70mmHg 

• PR: 82PPM~ Normal 

•RR: 19CPM

SYSTEMIC EXAMINATION

• CVS- S1 S2 sounds are heard 

•CNS- normal

•No abnormality in muscle 

•Abdomen is tender 

PROVISIONAL DIAGNOSIS 

•This is a case of chronic pancreatitis with diabetic ketoacidosis 

INVESTIGATIONS  

TREATMENT 

• Inj. Tramadol 1amp in 100ml NS/ IV/ BD 

•Inj. Pantop 40mg IV/BD 

•Inj. Thiamine 1amp in 100ml NS/IV/BD 

•Syrup cremafine plus 15ml/PO/HS

• Insulin 5units TDS.