Final practicals-Short case:1802102002
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A 36 year old male patient farmer by occupation came to our hospital with chief complaints of pain in the abdomen since 45 days.
History of present illness:-
Patient was apparently asymptomatic 45 days back, then he noticed pain in abdomen which is of dragging type which is in the epigastric region. Patient also complains of nausea and loss of appetite.
No history of vomitings,constipation.
Past history:-
Patient is not a known case of diabetes, hypertension, CAD, asthma, TB, epilepsy, thyroid disorders. No history of any surgeries in the past.
Personal history:-
Patient has normal eating habits with mixed diet.
Appetite: low
Sleep: inadequate
Bowel and bladder movements: regular
Micturition: normal
Addictions:
Alcohol consumption- regular
Toddy since 15 years
Whisky 250 ml once in 2 days for 1 year.
Family history:-
No significant family history.
Treatment history:-
Patient had not undergone any treatment prior. He is not allergic to any known drugs.
GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative and well oriented to time, place and person.
No signs of pallor, icterus, cyanosis, clubbing and generalised lymphadenopathy.
VITALS:
Temperature: afebrile
Blood pressure: 110/ 80 mm Hg
Pulse rate: 90 beats / min
Respiratory rate: 20/ min
Spo2 : 97% at room temperature
SYSTEMIC EXAMINATION:
INVESTIGATIONS:
COMPLETE URINE EXAMINATION :-
LIVER FUNCTION TEST :
BLOOD UREA
HIV 1 and 2 ELISA
Ultrasound:-
ECG
Provisional diagnosis:-
Acute pancreatitis.
