A 34 year old male with decreased appetite

A 34 year old male, resident of chitiyala , driver by occupation came to hospital on 19/9/22 with 

CHIEF COMPLAINTS
       Decreased appetite and body pains since 3 days and vomitings since 2 days.

HISTORY OF PRESENT ILLNESS 
     The patient was apparently assymptomatic 3 days ago.The he had decreased appetite and body pains and generalised weakness . Then he had vomitings 2 days ago which were projectile and foul smelling.

PAST HISTORY
      No history of DM
      No history of HTN 
      No history of CAD , Asthma , epilepsy, TB 
      No past surgeries

FAMILY HISTORY 
        No History of DM , HTN ,CAD , TB,                Asthma 

PERSONAL HISTORY
       Married
       Driver by occupation
       Mixed diet 
       Decreased appetite
       Inadequate sleep 
       Normal bowel movement
       Normal micturition
       Alcoholic 
       Smoker
       No known allergies 
       
 GENERAL EXAMINATION 
       Conscious and coherent
       Moderately built
       Moderately nourished 
       No pallor
       No icterus
       No cyanosis, clubbing of fingers ,           lymphadenopathy, pedal oedema 
  
VITALS 
 Temperature - 98.8F
  Pulse rate - 89beats /minute
  Respiratory rate - 26cpm
  BP  -120/80 mm of Hg
  SpO2 - 96%
  GRBS -89mg% 

SYSTEMIC EXAMINATION
 CVS 
 No thrills 
 S1 S2 + 
 No cardiac murmurs

RESPIRATORY SYSTEM
Centrally located trachea 
Vesicular breath sounds 
No dyspnea
No wheezing 

ABDOMEN
Scaphoid shaped abdomen
 No tenderness
No palpable mass
 
CNS 
Conscious and coherent
Normal speech

INVESTIGATIONS 
Ultrasound scan
 
TREATMENT
1. IV Fluids - NS and RL
2.Inj. PAN 40/IV /OD/BBF
3.Inj. Zofer 4mg /IV

PROVISIONAL DIAGNOSIS 
Alcoholic hepatitis

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