50 year old female with Dysphagia under evaluation Anemia under evaluation ?ATT induced Steven Johnson ?Plummer Vinson AKI secondary to ?pre renal ?UTI k/c/o DM,HTN, HYPOTHYROIDISM, RHEUMATOID ARTHRITIS

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47 year old male, lorry driver by occupation, came to hospital with C/O Pain Abdomen, vomitings and fever since 3 days.

HOPI:

Patient was apparently asymptomatic 3 days ago, and then he developed pain abdomen- intermittent, throbbing type of pain, initially in epigastric region and later progressed to diffuse type since 3 days, associated with vomitings-1 episode, non bilious, non projectile, food as the content.

- Pain Abdomen increases after food/water intake

- - Fever: low grade, intermittent, not associated with chills and rigors, burning micturition, headache, neck pains, relieved with medication.

- Had similar complaints in month of November, lasted for one day, subsided with medication.

- - Patient has not passed stools since 3 days

- Passing flatus +

- - Last alcohol intake 5 days

PAST HISTORY: Not a K/C/O HTN/DM/BA/Epilepsy 

Past surgical history : 

An implant was placed and removed in his left thigh due to femur fracture which happened because of bike vs bike accident 15 years ago 

PERSONAL HISTORY:

Diet- mixed

Appetite- decreased since 3 days

Sleep- normal

Bowel and bladder movements- regular

Addictions- 

Alcoholic since 10yrs, daily 180ml, last alcohol intake 5 days ago

Smoker-daily

FAMILY HISTORY:

Diabetes-2 brothers, on medication 

Hypertension- mother , on medication 

GENERAL EXAMINATION-

Pt C/C/C

No pallor/Icterus/cyanosis/clubbing/koilonychia/ generalised lymphadenopathy / pedal edema 

Temp- afebrile

PR- 92 bpm

BP- 170/80 mmhg

Spo2-95% @RA

SYSTEMIC EXAMINATION -

CVS: S1 S2 +,No murmurs

RS: BAE+, NVBS heard

P/A: distended,tenderness+, diffuse guarding+, bowel sounds+ 

CNS: NFND 

Investigations : 

2d echo

       USG abdomen

Chest x-ray pa view

Ecg

DIAGNOSIS :

EROSIVE DUODENITIS  2° TO ALCOHOLISM WITH ALCOHOL DEPENDANCE SYNDROME , TOBACCO DEPENDENCE SYNDROME

 WITH DENOVO DM 

Rx:

1.NBM till further instructions 

2.IVF NS,RL,DNS @100ml/hr

3.INJ.PANTOP 40 mg IV BD

4.INJ.ZOFER 4mg IV SOS

5.INJ.TRAMADOL 1amp in 100ml NS IV TID

6.INJ.THIAMINE 1amp in 100ml NS IV TID

7.GRBS 4th hourly

8.I/O Charting

9.Monitor vitals 4th hrly  

21/1/2022

Psychiatry referral 

Gastro referral :