49 yr male with abdominal pain

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Chief complaints:

Abdominal pain since 20 days

Vomitings since 20 days

Shortness of breath since 20days

Constipation since 7days

HOPI:

Patient is apparently asymptomatic 7 years back, he complained of stomach pain since 7 days which is pricking type and radiating to back  it is not associated with nausea,vomiting.

He went to the hospital and given IV fluids with analgesics and got relieved.

One month back he is complaining of abdominal pain which is pricking type and radiating and associated with decreases in appetite and vomitings(2episodes /day)Since 20 days which is non bilious and content is food particles. He went to hospital at nakerekal and underwent endoscopy.

As he is not taking any food and there is a hypoglycemia attack and dizziness is experienced by patient.and admitted to hospital.

Patient is complaining of difficulty in passing stools, he is only passing stools when he is on laxative and stools are story hard and pallets in nature , there is no complaints of farting.

PAST HISTORY:

He is known a known case of diabetes since 3 yrs and on regular medication

He is known patient of tuberculosis 10 years back and treated with medication for 9 months and relieved.

1 year ago he consulted ortho with chief complaints of left lower limb pain at knee.. there is history of fall on road while walking.

Not a k/c/o HTN, EPILEPSY OR ASTHMA

PERSONAL HISTORY:

He has mixed diet

Normal appatite 

Adequate sleep

Decreased bowel movements and regular bladder .

Consuming tobacco since 10yrs 

He is taking alcohol and toddy since 10yrs which is weekly twice and amount of 90ml if alcohol, 1000ml if toddy.

And he stopped taking alcohol since 1yr.

GENERAL EXAMINATION:

Pt is conscious coherent and well orientated to time place and person.

There is no pallor, icterus , clubbing, cyanosis, lymphadenopathy, edema

CVS: S1 S2 heard

R/S: BAE+

P/A: 

Shape of abdomen: scaphoid with normal contour, abdomen moving with respiration, there are no scars, swellings , sinuses, no visible peristalisis and no visible pulsations, no local rose of temperature, no tenderness,no cough impulse, no organomegaley, no swellings palpable, no gaurding/ridgidity, rebound tenderness,

FEVER CHART 

INVESTIGATION CHART 

CHEST XRAY

ENDOSCOPY

CT ABDOMEN 

ENMG REPORT

29/09/22

ANTALGIC GAIT 

Diagnosis:

Chronic pancreatitis with type 2 diabetes mellitus since 3yrs with de-myelinating neuropathy in both lower limbs and old TB case.

Treatment:

1) IV FLUIDS NS@100ml/hr infusion

2) IV FLUIDS 0.9%NS @50ml/hr infusion 

3) GRBS charting.

4) INJ. OPTINEURON 1amp in 100ml NS OD

5) INJ. PAN40mg IV/OD