A 35 year old male with generalised weakness and pain abdomen

 A 35 year old male patient resident of suryapet and carpenter by occupation presented with chief complaints of weakness ,shortness of breath and pain abdomen since 10 days .

HOPI.: The patient was apparently asymptomatic 10 days ago.Then he developed diffuse pain in the abdomen which  was sudden in onset ,intermittent, continous ,dragging type without any aggrevating or releiving factors.He also complained of vomitings since 3 days which was non bilious and projectile. He also complained of constipation after admiting .They consulted a RMP following which there was a relief in the symptoms but after 2 days again the symptoms reappeared. 

There is no history of burning micturition 

               No history of cold or cough 

              No history of increased or decreased urinary frequency 

Past History : No history of Diabetes Mellitus

                         No history of Hypertension 

                         No history of epilepsy 

                         No history of TB and asthma 

                         No history of blood transfusions

                         No previous surgical history 

Personal History: 

             Appetite: Good when he is not drinking alcohol

            Diet : Mixed

            Sleep : Adequate 

            Bowel : Abnormal 

             Bladder : Normal 

             Addictions: He drinks whisky 1 bottle per day since 10 years. 

No history of allergies 

Family history : No significant family history 

General Examination:

Examination was performed in a well ventilated room after taking the consent of the patient .

Moderately built 

Conscious and coherent 

Well oriented to place ,time and person 

Icterus present

 




No Pallor 

No cyanosis

No clubbing of fingers 

No lymphadenopathy 

No pedal edema

Vitals:

Temperature : febrile 

Heart rate : 103bpm

Pulse : 103bpm    with normal volume and rhythm 

Respiratory Rate: 20cpm

BP : 110/70mmhg

Systemic examination 

Abdomen 

Inspection : Distended abdomen 




                       No scars 

                       No surgical marks 

Palpation : tenderness present all over abdomen but more at right hypochondriac region 

Liver is palpable 

Percussion: Fluid thrill is present lll

                      No shifting dullness 

Auscultation : bowel sounds not heard 

CVS Examination: 

        S1 and S2 heard without murmurs

Respiratory System Examination: 

Central position of trachea

Breath sounds heard 

CNS Examination: 

Patient is conscious 

There are flapping tremors 

Cranial nerves, sensory system and motor system are normal .

Diagnosis : Alcoholic Liver disease 


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