33 yr male with pain abdomen

Case:
33 yr male came with chief complaints of 
- Epigastric pain since 5 yrs
HOPI:
Patient was apparently asymptomatic 5 yrs ago then he developed epigastric pain he went to local hospital 5 yrs ago where he was given medication and again after 4 years he presented with loin pain went to local hospital where he was diagnosed with renal calculi and now presented with epigastric pain since 1 month ,insidious in onset ,pricking type,non radiating, reduced after taking food, burning sensation after taking spicy food,relieved after medication.
-No fever , vomiting, burning micturition, diarrhoea 
Past history:
Not a known case of DM,HTN, Asthma, Epilepsy,CVA,CAD,TB
Present history:
Appetite -Nornal
Diet-Mixed
Sleep -Adequate
Bowel and bladder habits -Regular
No addictions
General Examination:
Patient is conscious, coherent, co-operative
Well oriented to time, place and person
Moderately built and nourished 
- No pallor , icterus, cyanosis, clubbing,pedal oedema, lymphadenopathy
Systemic Examination:
Abdominal Examination:
Inspection:
-Shape of abdomen - slightly distended 
-Umbilicis - Central 
-All quadrants moving equally with respiration
- No scars,sinuses, engorged veins,dilated vessels 
Palpation:
- No local rise of temperature,no tenderness
- No organomegaly
Auscultation:
-Bowel sounds heard 
CVS: S1S2 Present
RS: BAE Present,NVBS
Investigations:
Provisional Diagnosis:Non ulcer dyspepsia 

Popular posts from this blog

57/F with low back ache

Image
Case: A 57year old female came with chief complaints of - Low back ache from 10 years -Excessive lacrimation from 10 days -Epigastric pain from 10 days HOPI: Patient was apparently asymptomatic 10 years ago , then she fell from steps and after 1 year she has back ache and went to hospital in bhopal  where she was given medications and 4 years ago she again fell on road and went to hospital in Hyderabad where she was given lumbar support belt and medications,now she came with low back ache, squeezing type , radiating to both lower limbs - Excessive lacrimation from 10 days -Epigastric pain from 10 days,burning sensation Past history: K/C/O HTN ,not on regular medication No DM,Asthma, Epilepsy,TB,CVA,CAD Present history: Appetite:Reduced Diet :Mixed Sleep : sleeplessness  at night from 6 months Bowel and bladder habits -Regular Addictions :Chews betel leaf  6-7 / day from 35 years General Examination: patient is conscious, coherent, co-operative, well oriented to time, place and person M
Read more

Medicine blended assignment

I have been given the following cases to solve in an attmept to understand the topic of 'Patient clinical data analysis' to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and diagnosis and come up with a treatment plan.                                                     This is link of questions asked regarding cases: http://medicinedepartment.blogspot.com/2021/05/online-blended-bimonthly-assignment.html?m=1                                           Name: Grandhi.N.D.L.S.Srujini           Rollno:41                                                          Below are my answers for the assignment:.                                                     1) Pulmonology.                                              A)https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html Questions: 1) What is the evolution of the symptomatology in this patient in terms of an event timeline an
Read more