A 55 year old male patient with pain in abdomen

Hello, I am Harshitha Shalini , a 5th semester medical student.  This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.

A 55 year old male patient, resident of Yadadri came with

CHIEF COMPLAINTS :

Pain in abdomen since 2 days.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 8 days back, then he developed pain in epigastric region Associated with 2 episodes of vomitings, which has food particles as content. Pain was sudden in onset, gradually progressive, intermittent and dragging type. Pain was aggravated with alcohol intake. Burning sensation is also felt over peri umbilical region.

Patient initailly 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  pain was intermittent 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.

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 freshed 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 

Chest X ray


Provisional diagnosis : 
 
Acute on chronic liver disease ? Alcoholic hepatitis ? 
K/c/ of alcohol and tobacco dependence syndrome with hypokalemia ? Acalculous cholelithiasis ? Esophagitis ? Hepatic encephalopathy 

Treatment -
1  Inj diclo 0.5 mg iv stat 
2  inj pan 40 iv stat 
3  inj  buscopan iv stat 

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