25 year old male with abdominal pain

 Chief complaint: 

25 year old patient resident of Nalgonda who is a painter by occupation is presented to the general medicine ward on (7-6-2022)with chief complaints of pain in the

abdomen since 3 days.

History of presenting illnesses.

Patient was apparently asymptomatic 5 year’s ago , then he started consuming alcohol and gradually increased to 12 to 18 units per day. 

He had tremors and sleep disturbances on taking alcohol, cravings for alcohol are present.

Along with alcohol he started consuming cigarettes dice 3 years 4 to 5 per day. He complains of difficulty in passing stools if he doesn’t smoke cigarettes.

2 months ago he was admitted in government hospital in Nalgonda due to weakness , decreased appetite and had hallucinating behaviour there he was accordingly treated and recovered with in 2 days . He was diagnosed with alcohol withdrawal syndrome and was admitted in DAC.

While he was in DAC he had Severe abdominal pain and was admitted in the general medicine department.

Patient complained of abdominal pain in the epigastric region and hypochondrium region and it was radiating to the back and reduced on leaning forward.


Past history:

No similar complaints in the past .

Negative history of diabetes, hypertension,CAD, Asthana, epilepsy 

Personal history:

Diet: mixed 

Appetite: decreased 

Sleep: inadequate 

Bowel and bladder movement: not regular 

Addictions : alcohol and tobacco consumption.

Family history:no similar complaints in the family.

Drug history:

General physical examination:

Patient was conscious, coherent and cooperative.

Underbuilt and undernourished .

Pallor- present

Icterus , cyanosis, clubbing, koilonychia, generalised lymphadenopathy, Edema  is absent.

Vitals:

Temperature: a febrile 

Pulse:

Respiratory rate:

Blood pressure:

Systemic examination:

CVS: s1 and s2 heard

               

CNS: No focal neurological deficit.

Abdominal examination:

Shape : scaphoid 

Umbilicus: central and inverted.

Scars ,striae and sinuses - absent.

Dilated veins in standing position- absent.

Visible peristalsis and pulsations are absent.

PALPATION 

Local rise of temperature- absent 

Tenderness - absent 


Investigation:






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