45 yr old pt with melena

December 02, 2020

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Case presentation:

45 yr male patient presented to the opd with

C/o : generalized weakness since 6months, increased since one week

Black coloured stools since 6 months

Abdominal distension since 6 months, increased since one week .

pain and burning sensation in the epigastrium since 6months .. increase with food intake , associated with vomiting, immediately after food intake .

loss of appetite since 6 months

Progressive Loss of weight since 6 months

Fever since 6 months, continuous , reduced with medication, low grade , .

constipation since 6months .once in 3 days .

Giddiness since 6 months.. , h/o fall due to giddiness and no h/o loss of consciousness

Pedal edema since 3 months .. pitting the from ankle to knee .

Patient was apparently asymptomatic 6 months back , then the patient developed

Black coloured stools, associated with constipation, patient passed stools once In 3 days . Associated with pain abdomen in the epgastruim since 6 months. , increased after taking food .

Patient had history of vomitings , non bilious, non projectile, contains food particles,, immediately after taking food , associated with pain in the epigastrium, and pain relieved after vomitings..

Patient had abdominal distension since 6months , on and off . Not associated with pedal edema(grade 2) b/l from ankle to knee , pitting type.. Associated with facial puffiness on and of.

Patient complains of fatigue , generalized weakness and generalized body pains since 6months, associated with giddiness .And has history of fall due to giddiness 3months back , with no history of loc.

Patient is not able to do his regular agriculture work due to the illness

Patient is a k/c/o chronic alcoholic since 3year, consumes 36oml of whiskey ,cheap liquor daily .

not a smoker

Pateint has h/o bleeding per rectum one year back for 8 months and then he was diagnosed with piles and was operated and the bleeding was relieved.

Patient is not a k/c/o htn , dm , asthma, epilepsy, thyroid disease

Diet :mixed by

appetite: normal

Bladder and bowels:constipation since one year . Micturation normal .

Sleep:inadequate.

addictions: alcoholic since 3 yrs,takes 360 ml of whiskey daily(cheap liquor)

vitals:

temp:afebrile