A 31 year old male with chief complaints of vomiting
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan
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 ATTENDERS
CHIEF COMPLAINTS:
Vomitings 7-8 episodes
Pain epigastrium
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 1 day back and then he developed vomiting of 7-8 episodes after consumption of alcohol which was non bilious, non projectile, not tinged with blood,food particles as content.
Pain aching type of pain in epigastrium sudden in onset non radiating relived on taking medications
H/O hallucinations since 3 yrs auditory and visual hallucinations no suicidal tendency some times he behaves aggressively
No H/O fever with chills, cold , cough,headache
No H/O jaundice, pruritis, diarrhoea, constipation
No H/O burning micturition, hematuria , oliguria
No H/O breathing difficulty, chest pain
PAST HISTORY:
No similar complaints in the past
Not a known case DM, HTN, Bronchial asthma, epilepsy, CVA, CAD
MLC CASE history of fall under the influence of alcohol 5days back
Periorbital swelling on the right eye with multiple abrasions on the skin on right side with sub conjunctival haemorrhage on the right side
PERSONAL HISTORY:
Married
Mixed diet , Appetite normal
Normal bowel and bladder movements
He is alcoholic consumes (since 2016)12-13 quarters daily according to CAGE score he has dependency to alcohol , Allergic to egg , chicken
DAILY ROUTINE
Patient wakes up at 6' O clock , then he goes to gym for 1 hour morning he will be having tea and breakfast
10 to 1pm goes to work ( auto driver)
Then takes rest from 1 to 4 pm
Again 4 to 8 drives auto and after 8 pm he eats dinner , scrolls phone for about 1 hour and then goes to sleep
Psychiatric problem
Patient was receiving treatment for 3 years for auditory and visual hallucinations no suicidal tendency some times he behaves aggressively
FAMILY HISTORY:
Not significant
GENERAL EXAMINATION
Pt is c/c/c
No pallor,icterus,cyanosis, lymphadenopathy,clubbing,edema of feet
VITALS
Temperature:98.6 F
Pulse rate:75/min
RR : 17 cpm
BP: 130/80
SpO2: 98% at room air
GRBS : 168 mg%
SYSTEMIC EXAMINATION
CVS: S1+,S2+ , no murmurs
RESPIRATORY SYSTEM: Presence of BAE with normal vesicular breath sounds and no adventitious sounds
Trachea central
ABDOMEN
- Shape of abdomen : obese
- No tenderness , palpable mass
- Hernial orrifices : Normal
- No fluids , bruits
- Liver and Spleen are not palpable
- Bowel sounds : Yes
CNS
Speech : Normal
Level of conscious : Conscious
No neck stiffness
No kerning's sign
Cranial system : NAD
Motor system : NAD
Sensory system : NAD
Glassgow scale : 15/15
Reflexes-
Biceps Triceps Supinator Knees Ankle
RL:. 2+ 2+ 2+ 2+ 2+
LL:. 2+ 2+ 2+ 2+ 2+
Tone: Rt .UL :Normal
Lf. UL: Normal
Rt. LL : Normal
Lf. LL: Normal
Power: Rt .UL: Normal
Lf. UL: Normal
Rt. LL: Normal
Lf. LL: Normal
Tremors were present
Cerebral signs :
Finger nose in-coordination : no
Knee heal in-coordination : no
Gait : NAD
Examination of ENT , Teeth and Oral cavity , Head and neck normal
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