A 50 year old male patient with a complaint of abdominal pain
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Chief complaint
A 50 year old male patient farmer by occupation came to the casuality with the chief complaints of abdominal pain since 1 month
HISTORY OF PRESENT ILLNESS :
Patient was apparently asympomatic 1 month back, then he developed abdominal pain after consumption of food in epigastric region. Squeezing type of pain,non radiating,increases after consumption of food relieved on its own.
No history of fever ,weightloss,vomitings, diarrhoea and constipation
HISTORY OF PAST ILLNESS :
N/k/c/o DM, HTN, Asthma , epilepsy, TB .
No history of similar complaints in the past.
PERSONAL HISTORY :
Diet - Mixed
Appetite - Normal
Sleep - Adequate
Micturition-normal
Bowel and bladder movements- Regular
Addictions -Patient consumes alcohol since 30 years
Zsmokes cigarette (8-10) or full pack since 30 years
chews pan (3-4 times )daily.
FAMILY HISTORY :
No significant family history
DRUG HISTORY :
No allergies to known drugs
NO history of previous medication
GENERAL EXAMINATION :
Patient was conscious, coherent, cooperative and well oriented to time place and person
Patient was well nourished and well built.
No H/o pallor, icterus, cyanosis,generalised lymphadenopathy, clubbing of fingers ,pedal edema
VITALS:-
Temperature: afebrile
Pulse rate:88 bpm.
Respiratory rate:16 cpm
Blood pressure: 120/80 mm Hg
SYSTEMIC EXAMINATION :
ABDOMEN-: By taking consent from the patient examined in a well lited room
Inspection:
Shape of the abdomen- Scaphoid
Flanks: flanks are free
Umbilicus- central and inverted.
no sinuses and scars are seen.
No engorged veins
Palpation:
No local rise of temperature
No tenderness
No palpable mass
No organomegaly.
Percussion:
No Fluid thrill
No shifting dullness
Tympanic note on percussion of abdomen
Auscultation:
Bowel sounds are heard
RESPIRATORY SYSTEM :
Chest is bilaterally symmetrical
Trachea is central
Movements with respiration are equal on both sides
Bilateral air entry present
Resonant sounds on percussion
CVS :
S1&S2 heard
No murmurs
CNS-:
Consious, coherent ,cooperative
Speech normal
No neck stiffness
Motor system normal
Sensory system normal
Able to percieve-:pain , temp.
Cranial nerves : intact
PROVISIONAL DIAGNOSIS :
Gastritis
Cholelithiasis
Cholecystitis
Liver disease
INVESTIGATIONS:
Complete blood picture
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