A32 yr old male pt.with metabolic syndrome


Case History and Clinical Findings
C/o of giddiness since 3 months last episode on October 16, 2022 one episode per day one episode
last 10 to 20 secondsc/o of vomiting in the early morning only water no food particles after passage of
stools in morning since three months today no episodeC/o of chest pain diffuse type (on/off) (diffuse
type ) since 2-3 monthscomplaints of pain in epigastric region since 2 to 3 months only on
pressingC/o of increased frequency of urine since two years more in morningC/o of decreased
appetite since three monthshistory of past illness:History of renal calculi in right kidney 5 years back
history of renal calculi in left kidney 4 years back relieved on medicationHistory of jaundice two times
at the age of 4 years not a known case of diabetes mellitus hypertension, CVA,CAD, epilepsy, TB
,asthmaPERSONAL HISTORY :-Diet : mixedapetite:- decreased since three monthssleep ;
adequatehabbits :- dinrks beer monthly once, smoking 3-4 cigarettes per daygeneral examination:-pt
is c/c/cno pallor , icterus , cyanosis, clubbing, lymphadenopathy, pedal edemavitals :-bp;-130/80 mm
hgpr :-90bpmtemperature :- afebrilespo2:-98% on RAsystemic examination:-cvs : s1s2 heard no
murmursr/s ; blae + no added soundsp/a : soft tenderness in epigastric regioncns; no fndBRIEF
COURSE IN HOSPITAL :-Patient came with complaints of of giddiness since 3 months last episode on October 16, 2022 one episode per day one episode last
10 to 20 seconds ,vomiting in the early morning only water no food particles after passage of stools in
morning since three months ,increased frequency of urine since two years more in morning ,chest
pain diffuse type (on/off) (diffuse type ) since 2-3 months , patient have been evaluated and routine
investigations patient was having metabolic syndrome patient have been counciled about the disease
and have been adviced lifestyle modifications.
Investigation
USG:
Impression: grade one fatty liver with mild hepatomegaly suggested review in fasting state for GB
pathology
Diagnosis
METABOLIC SYNDROME WITH CHRONIC HEPATITIS , NAFLD
Treatment Given(Enter only Generic Name)
monitored vitals
Advice at Discharge
1.TAB.ZOFER 4MG PO/SOS
2.EXCERCISE DAILY FOR 30MINS , WEEKLY 150MINS, NOT MORE THAN GAP FOR 2 DAYS IN
BETWEEN
3.STRICT NORMAL DIET
4. COMPLETE ABSTINENCE OF ALCOHOL AND SMOKING.
Follow Up
REVIEW TO GENERAL MEDICINE OPD AFTER 1 MONTH.
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR
ATTEND EMERGENCY DEPARTMENT.

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