A 36 year old male with vomiting
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CHEIF COMPLAINTS
36 year old male shopkeeper of occupation came to opd with cheif complaints
Vomiting since 2months
Abdominal pain since 2months
HISTORY OF PRESENTING ILLNESS
Patient was apparantly asymptomatic 2 months the he developed vomitings which were insidious in onset and progressive in nature
He generally has vomiting episode 3-4 hours after eating food and also uncomfortable feeling in abdomen like squeezing sensation in abdomen associated with pain which was non radiating non referring aggrevates on taking food and no relieving factors
Vomiting particles are generally recently eaten food particles and colour of content is yellowish colour ,non bile stained and not blood stained. Vomiting generally occurs 3 to 4 times a day some days more than 5 times a day
By physical assessment eyes are sunken suggesting subcutaneous fat loss of orbitals , muscle depletion near the temporalis . Shoulders and clavicle are more prominent than expected . By dietary assessment patient is taking less food compared to 2 months ago . By the evidence of unintentional weight loss and required energy intake indicates malnutrition is present
H/O nausea ,giddiness, regurgitation of food is present
H/O lethargy and weakness due to excess vomiting
H/O Obstipation is also present
H/O unintentional weight loss is present
H/O Jaundine for which he took medications which didn't work properly
No H/O dysphagia , diarrhea, abdominal distension , hematemesis ,heart burn
NO H/O chest pain, shortness of breath, Paroxysmal nocturnal dyspnea
PAST HISTORY
No H/O hypertension, diabetes ,CAD , epilepsy , Tb, thyroid disorders
No history of any previous surgeries
PERSONAL HISTORY
Diet -mixed
Appetite- normal
Sleep - disturbed due to pain in abdomen
Bowel and bladder - bowel movements are irregular ( i.e once in every 5 -6 days) but bladder function is normal
Addictions- non smoker and non alcoholic but have habit of chewing tobbaco
GENERAL EXAMINATION
patient is coherent, cooperative,conscious well oriented to time place and person thin built and poorly nourished
Pallor is present
Icterus - no signs which indicates jaundice was resolved
Clubbing - no
Cyanosis - No
Peripheral lymphadenopathy- No
Edema - no
VITALS
Temperature- afebrile
Pulse rate - 72bpm
RR - 15 cpm
Bp - 90/60 mm hg
Spo2 - 98%
SYSTEMIC EXAMINATION
Abdominal examination
On inspection
Shape of abdomen - scaphoid with no flank fullness
Umblicus- is centrally placed and inverted
Movements of abdominal walls are normal
Skin over abdomen - no pigmentation , no scars , no dilated veins are present
On palpation
No local rise in Temperature
Mass is felt near the right side of Umblicus
Liver , spleen are not palpable
On percussion
No fluid thrills
No Shifting dullness
On auscultations bowels sounds are reduced
CVS:
Inspection:
There are no chest wall abnormalities
The position of the trachea is central.
Apical impulse is not observed.
There are no other visible pulsations, dilated and engorged veins, surgical scars
Palpation:
No local rise of temparature and no tendersness
Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line
Position of trachea was central
Auscultation:
S1 and S2 were heard
There were no added sounds / murmurs.
Respiratory examination :
Inspection: chest shape : bilaterally symmetrical elliptical
Movement : bilaterally symmetrical
No scars , sinuses , engorged veins
Trachea appears to be central
Palpation: No rise in temperature and no tenderness , Apex beat felt at 5 intercostal spaces.
Expansion of chest is bilateral symmetrical in anterior, apical and posterior areas.
Trachea location central .
Tactile vocal fremetus : resonant in all areas
Percussion: All areas appears are resonant.
Auscultation:BAE present,
Normal vesicular breath sounds are heard
CNS examination :
HIGHER MENTAL FUNCTIONS- Normal
Memory intact
CRANIAL NERVES :Normal
SENSORY EXAMINATION
Normal sensations felt in all dermatomes
MOTOR EXAMINATION
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
No focal neurological deficits seen
PROVISIONAL DIAGNOSIS
Intestinal obstruction ? Due palpable mass at
May be gastroesophagial reflux disease due previous history gastritis and oesophagus infection
INVESTIGATIONS
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