General medicine case presentation
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A 34 year old male patient who is working at store to print wedding cards from Suryapet came to casuality with cheif complaint of abdominal pain since 20 days.vomitings since 20 days .
History of present illness:
Patinet was asymptomatic 2 years back . Patient has habit of drinking alcohol from 15 years . He drinks 360 ml/day . Since last 2 years patient is suffering with recurrent episodes of abdominal pain and recurrent episodes of vomitings.Abdominalpain gets relieved on sitting.patient is lossnot consuming sufficient amount of food due to loss of appetite .
Since last 20 days patient experiencing generalized weakness so that he stop going to work.he also experiencing dysopnea and 1 episode of vomiting blood tinged .and dark coloured stools . He also experiencing low grade fever intermittent no diurinal variation. He also lost s weight.around 12 kgs . He also have increased abdominal pain in epigastric region.patient became anemic .
History of past illness:
Patinet is not a known case of Diabetesmellitus, hypertension,asthma , tuberculosis,jaundice , epilepsy.
Family history:
No similar complications seen in family members.
Drug history :
patinet is not allergic to known drugs
Personal history:
Diet : mixed
Appetite: lost
Sleep: adequate
Bowel and bladder movements ; constipation
Micturation: normal
Habits: alcoholic , occasionally smoking.
Allergies : no known allergies
General physical examination:
Patinet is pallor
No cyanosis
No icterus
Malnourished
No clubbing of fingers
No lymphadenopathy
No edema of feet
Vitals :
Temperature: 98°F
Pulse rate : 84 bpm
Respiration rate : 18 cycle per min
Bllod pressure :120/89 mm hg
GRBS 102 mg
Spo2 99%
Systemic examination:
Cardiovascular system:
S1 and S2 heard
No murmurs heard
Respiratory system:
Location of trachea central
No wheezing sounds
Breathing sounds vesicular.
Abdomen:
Shape of abdomen : scaphoid
Abdominal tenderness grade 1 pain
No palpable masses
Hernial orifice is normal
Bowel sounds yes.
Level of consciousness:
Patient is conscious, coherent,and cooperative to time and place.
Speech is normal
Motor , sensory system noramal
All reflexes are normal.
Provisional Diagnosis: chronic pancreatitis.
Investigations:
Treatment:
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