General medicine 2

Hi, iam maheshwari  of 3rd semester. This an online E logbook to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.

The patient’s consent was taken prior to history taking and examination of his condition.
Cheif complaints-
Pain in abdomen (more in epigastric region ) vomiting (multiple episodes containing food particles) non projectile non billous alcohol binge+ 
History of present illness-
H/o outside food intake 
Pain in the Abdomen and multiple episodes of vomiting and complaining of tremors and sleep disturbances.
Craving for alcohol 
History of past illness
No DM/HTN/CAD/CVA/ASTHMA /ANY OTHER SYSTEMATIC ILLNESS 
CHRONIC ALCOHOLIC- 180ml/day since 5 years 
Personal history-
Married 
Occupation - ambulance driver 
Appetite-lost 
Non-vegetarian 
Bowel -regular 
Micturation-normal 
No allergies 
Habits-alcohol regular
            Tobacco chewable 
             No drug use 
Family history-
No family history 
Physical examination-
No pallor 
No icterus 
No cyanosis 
No clubbing of fingers
No lymphadnopathy 
No Oedema
No malnutrition 
vital signs-
Temperature-98.6
Pulse rate -66/minute 
Respiratory rate-14/min 
Bp -110/80
SYSTEMATIC EXAMINATION 
Abdomen 
Shape of abdomen-scaphoid 
Tenderness-no
Palpable mass-no 
Hernial orifices-normal
Freefluid-no 
Liver-not Palpable 
Spleen-not Palpable 
Bowel sounds-no
Cns
Conscious 
Speech -normal 
Cranial nerves-normal 
Sensory system-normal 
Motor system-normal 
Reflexes-normal 
Cerebral signs-normal 
Finger nose in coordination-yes 
Knee heel in coordination-yes
Investigation - Rft Lft serum amylase and serum lipase and USG 

Diagnosis-
Accute gastroenteritis 
Acute liver disease 
Renal caliculi 



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