27yr Male with pain abdomen since 3 years

May 29, 2023


 This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.



This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


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.



One point presentation/ localisation of pain  



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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