50 Y/M WITH PAIN ABDOMEN

- January 04, 2023

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The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.

CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDER

Chief complaints

A 50 year old male resident of Katangur, daily wage worker by occupation presented to OPD on 2/1/23 morning with chief complaints of pain Abdomen since 6hours.

History of present illness:

Patient was apparently asymptomatic 6hours then he developed pain Abdomen which was sudden in onset at 12am on 2/1/23 and gradually progressive. Pain was diffuse but more in umbilical and left lumbar region. It was colicky type and non radiating but continuous in nature. History of alcohol intake present. There are no aggravating and relieving factors. No h/o fever, nausea, vomiting and loose stools.

Past history :

Similar complaints in the past 2 years back and was diagnosed as Acute pancreatitis.

Patient is know case of diabetes since 2 years and is on medication. Patient is not a know case of Hypertension, Asthma, tuberculosis, thyroid abnormalities and epilepsy.

Family history: not significant

Personal history:

Daily routine : He wakes up at 6 am and does his daily routine and goes for work and takes 3 meals daily. He drinks alcohol and smokes intermittently through the day and sleeps by 10 pm.

alcohol consumption 180 ml on an average per day

smoking 5-6 packs per day since 30 years, decreased to 5-6 cigarettes per day since last two years.

he gives a history of consumption of a mutton and fatty meals for the past 5 days continuously.

Diet: mixed

Appetite: normal

Sleep : disturbed since 2 days

Bowel and bladder movements: regular

Addictions: Chronic alcoholic since 30 years and takes 180ml per day on an average. Cigarette (tobacco) 5-6 packs daily since 30 years. 5-6 cigarettes currently since last 2 years.

Allergies : none

General physical examination:

Patient is conscious, coherent and cooperative. Moderately built and nourished, well oriented to time, place, person

Pallor : absent

Icterus : Present

Cyanosis : absent

Clubbing:absent

Lymphadenopathy: absent

Edema : absent

Vitals:

Blood pressure: 150/100 mm of Hg

Pulse rate: 65bpm

Respiratory rate: 20cpm

Temperature: Afebrile

Systemic examination:

Abdomen:

Inspection: Abdomen is distended, Umbilicus is central and inverted. All quadrants of Abdomen are moving accordingly with respiration. No visible scars sinuses or engorged veins.

Palpation: All inspectory findings are confirmed. Abdomen is soft and tenderness is present in the umbilical region and left lumbar region. No guarding, no rigidity, no hepatosplenomeglay and hernial orifices are free .

Percussion: no shifting dullness, normal liver span

Auscultation: Bowel sounds present.

CVS: S1 S2 present , no murmurs heard

CNS: No focal neurological deficits.

Respiratory system : Bilateral air entry present. Normal vesicular breath sounds heard.

CLINICAL IMAGES