55 year old male with pain abdomen since 2 days
A 55 year old male patient with pain abdomen since 2 days
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Date of admission - 11/07/2023
A 55 year old male patient bought to the casuality with chief complaints of abdominal pain since 2 days .
History of present illness -
Patient initially started drinking and smoking from 30 years .
From past 2 years patient was having epigastric pain for which he went to the local doctor and would get the treatment
It was like on and off pain which relieved on medication.
6 months back patient had severe epigastric pain went to near by hospital and got admitted for few days and got the symptomatic tretament and advised not to consume alcohol
Patient had again started consuming alcohol
Then after one month he had severe epigastric pain for which he got admitted in our general medicine department and was daignosed for alcoholic disease , alcohol withdrawal secondary to drug induced ( promethazine drug ) and he was advised not to consume alcohol
Then patient had again started consuming alcohol
Pateint was asymptomatic till 2 days back then he developed epigastric pain associated with vomitings 2 episodes .vomiting had food particles as content yesterday and coconut water today . Pain was sudden in onset and gradually progressive on and off episodes . Burning sensation over the prriumbilical region and constipation since 3 days
Past History:
Not a k/c/o DM, HTN
Previously admitted in the department of general medicine for alcoholic disease , alcohol withdrawal secondary to drug induced ( promethazine drug )
DAILY ROUTINE :
He is tractor driver by occupation . He wakes up at 5 am and gets frenshed up and drinks tea at 8 am and then he goes to work and come back by 10 am and then eats rice and then again he goes back to work and come by 2 pm . He goes to work and come back by 6 pm . He drinks tea and goes out for drinking and come back by 8 pm and then eats dinner and goes to sleep by 10 pm .
His daily routine has not changed much . He can do his daily activies as usual .
PERSONAL HISTORY
Occupation:. Tractor driver
appetite : normal
Diet : mixed
Marital status : married
Bowel movement : regular
Micturition: normal
Alcohol : regular from 30 years ( 150 ml )
Smoking : 15 beedis per day for 30 years
GENERAL EXAMINATION
Patient is conscious, coherent, co-operative.
There are no signs of icterus, clubbing, pallor, cynosis, lymphadenopathy and edema
Vitals :
Temp - afebrile
PR - 99 bpm
RR - 18 cpm
BP - 130/80 mm hg
SYSTEMIC EXAMINATION:
Cardiovascular System
Thrills- no
Cardiac sounds- S1, S2 +
Cardiac murmurs - No
RESPIRATORY SYSTEM
Position of trachea- central
Breath sounds- vesicular
No Dyspnea and wheeze
LOCAL EXAMINATION
INSPECTION -
Obese abdomen
Umbilicus central and inverted
All quadrants of abdomen moving equally with respiration
No scars , sinuses , engorged veins , visible palpations
PALPATION -
No local rise of temperature
Tenderness present in epigastric region
Perabdomen - soft non tender BS +
P/R - no masses , glove stained with stools
AUSCULATATION -
No bruits
ABDOMEN
Shape of abdomen- obese
tenderness - present at epigastric region
Palpable mass- no
Free fluid- no
Bruits- no
Liver- Not palpable
Spleen- Not palpable
Bowel sound- Yes
CENTRAL NERVOUS SYSTEM
Patient is coscious
Speech - normal
INVESTIGATIONS -
Usg
Provisional diagnosis :
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