General Medicine case 2
This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent.
Date of admission- December 17, 2021
A 29 years old male patient came with chief complaints of pain in abdomen since 4 months with frequent vomiting.
H/o present illness-
Patient was apparently asymptomatic 4 months back and then he had a burning type of pain in abdomen(epigastrium) radiating to the chest and then with frequent vomitings, 2-3 times per day after taking meals. He had a burning micturition and while passing stools. So whenever he had a pain he takes tablet pan 40mg medicine and feels relief.
In 2016 patient visited to hospital with similar complaints of burning type of pain in abdomen and vomiting with burning sensation while passing stools and urine and then he was diagnosed to have stomach ulcers through Endoscopy then he was under medication for 6 months.
He had a pain in calf muscle since 4 years.
PAST HISTORY:
N/k/c/o : diabetes mellitus, asthama, epilepsy and hypertension, TB.
K/c/o : Renal calculi since 4 months ( on homeopathy medication) .
Personal history-
Diet : mixed
Appetite- normal
Bowel and bladder movements - burning sensation while micturition and irregular bowel movements ( constipation)
Daily smoker he smokes 5 - 10 cigarettes or beedi's per day since 10 yrs.
He consumes alcohol occassionally since 10 yrs.
General examination-
Patient is conscious, coherent,cooperative.
Clubbing +
No icterus, pallor ,cyanosis, lymphadenopathy.
CLINICAL IMAGE'S:
Vitals :
PR- 75 bpm
RR- 16 cpm
BP- 90/60 mm Hg
SpO2- 98%
Differential diagnosis :
Peptic ulcer disease
Gastric cancer
gastroesophageal reflux disease
gastroenteritis
Provisional Diagnosis - Gastritis with UTl, Renal calculus suspecting .
Treatment :
Pantoprazole 40mg
Zinkomin plus
Pregabalin 75 mg
Comments
Post a Comment