50 year old with abdominal pain

March 15, 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 yr old male came to opd on 2/1/23 with chief complaints of abdominal pain since 6 hrs.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 6hours later he developed pain in Abdomen which was insidious in onset at 12am on 2/1/23 and gradually progressive.

Pain was diffuse but more in epigastrium.

It was colicky type, non radiating to back.

There are no aggravating and relieving factors.

No h/o fever, nausea, vomiting and loose stools.

H/o alcohol intake since 30 yrs.

PAST HISTORY:

H/o diabetes since 2 years and on medication.

Not h/o hypertension,tb, asthma, epilepsy.

PERSONAL HISTORY:

Daily Routine:

He wakes up at 8am and does his daily routine and does not go for work and takes 3 meals daily. He drinks alcohol and smokes intermittently through the day and sleeps by 10 pm.

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) 2-3 packs daily since 30 years.

Allergies : none

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative.

Moderately built and nourished.

Pallor : absent

Icterus : absent

Cyanosis : absent

Clubbing: present

Lymphadenopathy: absent

Edema : absent

VITALS:

BLood pressure: 150/100 mmHg

Pulse rate: 65bpm

Respiratory rate: 20cpm

Temperature: afebrile

SYSTEMIC EXAMINATION:

Abdomen:

Inspection:

Abdomen is obese, 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 Hepatosplemomegaly and hernial orifices are free .

Percussion:

no shifting dullness.

Auscultation:

Bowel sounds present.