19 YR OLD MALE WITH PAIN ABDOMEN
19YR OLD MALE
C/O PAIN ABDOMEN SINCE 3DAYS
C/O VOMITINGS 2 EPISODES SINCE 3 DAYS
C/O LOOSE STOOLS SINCE 3DAYS , 5 TO 6 EPISODES PER DAY.
HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 3 DAYS BACK, THEN HE DEVELOPED LOWER ABDOMINAL PAIN, SUDDEN IN ONSET, CONTINOUS, COLICKY IN NATURE AND RADIATING TO LEFT LOWER ABDOMEN, AGGRAVATING PAIN BEFORE DEFECATION, ASSOCIATED WITH VOMITING 2 EPISODES, NON BILIOUS, NON PROJECTILE, FOOD AS content, H/O LOOSE STOOLS SINCE 3DAYS 5 TO 6 EPISODES PER DAY, WATERY STOOLS.
H/O FEVER 1 EPISODE ASS. WITH CHILLS AND RIGOR , AFTER WHICH PATIENT WENT TO LOCAL HOSPITAL FOR ABOVE COMPLAINTS, WHERE CONSERVATIVE MANAGEMENT DONE.
H/O INTAKE OF MUTTON IN THE FUNCTION 3DAYS BACK.
NO H/O SIMILAR COMPLAINTS IN THE PAST.
G/E;
PT C/C/C.
PR: 115BPM
BP: 110/ 70MMHG
P/A: OBESE ABDOMEN , MILD TENDERNESS AT LEFT ILIAC FOSSA.
CBP
RFT
PROVISIONAL DIAGNOSIS: ACUTE GE ? VIRAL HEPATITIS.
TREATMENT:
1. INJ. PAN 40MG IV
2. INJ. ZOFER 4MG IV
3. IVFLUIDS - NS AND RL @ 70ML/HR.
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