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Cheif complaints :
HOPI
Patient was apparently asymptomatic 1 day back, then he developed diffuse abdominal pain which increased after food intake , non radiating pain, not relieved on medication.
No H/o Fever
No H/o vomiting
No H/o decreased urine output
No Abdominal rigidity
No H/o burning micturition
No H/o constipation
No regurgitation
No edema
PAST HISTORY
Not a known case of HTN, DM, CVA, TB, ASTHMA, Epilepsy.
No similar compliants in the past.
FAMILY HISTORY
Not significant
PERSONAL HISTORY
Diet - normal
Appetite Normal
Bowel movements - Regular
- Consumes alcohol
- Smoker
GENERAL EXAMINATION
Patient is examined in a well lit room.
Moderately built and nourished.
Icterus is present(sclera).
Clubbing is present.
No signs of pallor, cyanosis and lymphadenopathy.
VITALS
Temp - afebrile
Pulse rate - 87 bpm
Resp. rate - 16cpm
BP - 130/90 mm Hg
Spo2 - 98% at RA
SYSTEMIC EXAMINATION
CVS
S1 and S2 heard
No murmurs
Examination of abdomen
Shape - obese
No Tenderness
No palpable mass
No free fluid
Bowel sounds are heard
AG - 84 cm
CNS
Conscious, coherent and co-operative
Speech is normal
No meningeal signs
- Reflexes
Biceps Triceps Supinator Knee Ankle
Right ++ ++ ++ ++ ++
Left ++ ++ ++ ++ ++
- No cerebellar signs
Investigations
Serology
HBsAg - negative
HIV - negative
- ? Alcoholic liver disease
Treatment
1. Inj Thiamine 100mg IV/OD in100ml NS
2. Tab PAN 40mg Po/OD
3. Tab Udiliv 300mg PO/BD
4.Tab. Viboliv 500mg PO/OD
5. SYP SUCRALFATE 15 ml PO/BD
6.Tab DOLO 650mg SOS.
7. Syp Lactulose 15ml PO/BD
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