General medicine case
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A 34 year old male who works at printing shop came to the OPD with the chief complaint of abdominal pain since 1 years which got aggravated since 1 month. He also complaints of loss of appetite since 20 days & complaints of 1 episode of blood tinged vomitings 20 days back.
History of present illness :
Normal routine of the patient :
The patient wakes up by 4AM daily, as soon as he wakes he consumes alcohol,then he sleeps for sometime & there is no specific time for his breakfast,lunch and dinner. Since 2 months he has been experiencing generalized weakness, so much so that he stopped going to work.
The patient was apparently asymptomatic 15 back, then he started consuming whiskey 90ml 2 to 3 times per week and gradually increased to 360 ml / day in 15 yrs. Patient experiences sleep disturbance, tremors, when not consuming alcohol.
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
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 heard
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:
Investigations:
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