27yr Male with pain abdomen since 3 years
May 29, 2023
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I have been given this case to solve in an attempt 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 come up with diagnosis and treatment plan
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.
CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDERS .
CASE :
A 27yr old male , waiter by occupation, resident of narketpally came to OPD with chief complaints of
Pain abdomen since 2 months.
HISTORY OF PRESENTING ILLNES:
pt was apparently asymptomatic 3 years back after which he experienced pain abdomen sudden in onset , intermittent in nature , in epigastric region and right hypochondrium , which was on and off , releived after taking food , increased after taking spicy food and oily food and increased on consumption of alcohol.
Pain is preceded by bloating of abdomen for which he consulted gastroenterologist at Kim's where endoscopy was performed and was documented to be normal and was prescribed GASTRO kit ( as said by pt) which consists of three tablets per day which he used for 1 month and there was relief in symptoms.
2years back pt again expirenced similar complaints and again consulted doc at Kim's and endoscopy was done which was normal and was prescribed Tab.Gastro Ls which he used for 1 week , after which the symptoms didn't reduce and he went to NIMS punjagutta and consulted a gastroenterologist and barium meal studies were done was documented to be normal and was prescribed Tab. Pantoshade ( as said by pt) for 1 month and after usage of this symptoms reduced .
2 months back pateint again experienced same symptoms and was prescribed Tab.Rifogut and T.pantop 40mg at Kim's for 2 weeks and releive of symptoms was noticed
1 months back - pt consumed alcohol immediately following which bloating experienced followed by pain for which he went to doctor at Kim's and used the same medications like last time and was relieved with symptoms.
Since 1 week there is increase in pain which is disturbing his working capacity and so he has consulted us .
No h/o fever , vomiting, loose stools constipation.
N/k/c/o HTN DM CVA CAD TB ATHMA .
DAILY ROUTINE OF PATIEMT BEFORE ILLNESS:
Pt is waiter by occupation in a canteen in hospital, he has 15 days of morning shifts and 15 days of night shifts.
Routine in morning shifts:
6-7am - wakes up
8am- take tea and 2 biscuits
9am leaves for work
10-11am - have breakfast ( dosa / 3 idlies / 4 bondhas )
2pm- have lunch ( sambar rice maximum days)
4pm- tea and 2 biscuits
7pm - return back from work
9:30pm - have dinner
Routine in night shifts:
9-10 am - wakes up
10:30am - tea and biscuits
2:pm - lunch
4 pm - tea biscuit
7pm - goes to duty
9:30-10:00 - dinner ( rice , sambar or fries rice)
Due to illness pt have been eating curd rice for lunch and dinner for 3 months after consultation in NIMS as advised and also has stopped taking alcohol.
Personal history:
Diet : mixed
Appetite: normal
Sleep: adequate
Bowel bladder : regular
Addiction: alcohol occasionally 2pegs
General examination:
No pallor , icterus , cyanosis , clubbing , lympadenopathy , edema
Vitals :
Temp: afebrile
BP: 110/70 mmHg
PR: 80bpm
RR: 16cpm
Spo2: 98% at RA
Systemic examination:
P/A:
On inspection:
Shape of abdomen: obese abdomen
All quadrants moving equally with respiration .
No scars , engorged veins , sinus
Hernial orifice empty
Palpation:
No local rise of temperature
Tenderness in epigastric region
No guarding and rigidity
All inspectory findings confirmed
Percussion:
No free fluid
Auscultation:
Bowel sounds heard.
CVS: S1 s2 heard
RS: BAE NVBS heard.
Diagnosis: ACID PEPTIC DISEASE ?
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