General medicine case 7

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December 08, 2021

48 YEAR OLD MALE WITH ACUTE GASTRITIS

48 year old male farmer by occupation came with C/O pain abdomen since 10 days

C/O vomitings since 1 day

Patient was apparently asymptomatic 10 years ago,diagnosed with DM,HTN 10 years ago,on regualar medication since then.

C/O pain abdomen since 10 days,aggravated since 3 days.

H/O daily alcohol consumption since 5 days.

C/O vomiting since 1 day,10-11 episodes,food as content,subsided now.

No C/O fever,loose stools,cough,sob,burning micturition.

Past history:

K/c/o DM since 10 yrs,on T.GLIMI M1 OD.

k/c/o HTN since 10 yrs,on T.ATEN 50mg OD.

H/O recurrent pancreatitis. 

Not a k/c/o CAD,epilepsy, TB,asthma.

Personal history:

Diet - mixed

Appetite - normal

Bowel and bladder movements-regular 

Alcoholic since 10 yrs,occasional associated with episodes of binge drinking in between.

General examination:

No pallor,icterus,cyanosis,clubbing, lymphadenopathy, edema.

obese abdomen

Vitals on admission :

Temperature-98.2 F

PR- 72 bpm

RR- 20 cpm

BP-170/110 mmhg

GRBS-180 mg%

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 

K/C/O ACUTE ON CHRONIC PANCREATITIS 

K/C/O 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