63 years old MALE CAME WITH CHIEF COMPLAINS OF EPIGASTRIC PAIN 2 MONTHS AGO AND LEFT SHOULDER PAIN RADIATING TO BACK.

This is an 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. is an 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.


CHIEF COMPLAINTS 


63 years old male came with chief complains of Epigastric pain 2 months ago and  Left shoulder pain radiating to back. 

 HISTORY OF PRESENTING ILLNESS

Pt was apparently asymptomatic 2 months ago then he had pain in the epigastric region which is squeezing type non radiating and relieves on sleeping , aggravated on taking food.


Along with epigastric pain he also developed pain in the left shoulder region which is radiating to back centrally and cough is also present which productive , not blood stained, temporarily relieved on medication.


H/O pedal edema 2 months ago is also present which reduced on medication. 


No H/O fever

No h/o vomiting 

No h/o constipation

No h/o burning micturation 

HISTORY OF PAST ILLNESS 

He is a known case of hypertension since  10 years and diabetis type 2 since 10 years.

Not an known case pf tb, asthma ,epilepsy.


No past surgery. 

TREATMENT HISTORY 

Oral drugs for diabetis and hypertension.

On medication for the complaints  20 days.

PERSONAL HISTORY 

Diet:mixed

Appetite : decreased due to pain

Bowel and bladder: regular

Sleep: adequate

Addictions:alcohol,he takes 90ml whisky every day 10 years. 

FAMILY HISTORY 

No relevant family history.

GENERAL EXAMINATION 

Patient is conscious coherent cooperative well oriented to time place and person.

Moderately built and nourished 

No pallor ,icterus,cyanosis,clubbing,generalised lymphadenopathy , pedal edema.

Vitals 

TEMPE AFEBRILE

HR 

RR 

BP 

SpO2 98%













 PER ABDOMEN 

INSPECTION

Abdomen is obese   and round 

Umbilicus central

No scars 

No swellings 

No engorged veins 

 PALPATION 

All inspectory findings are conformed 

Tenderness in epigastric region.

No palpable mass 

No splenomegaly 

No hepatomegaly

PERCUSSION 

No shifting dullness


AUSCULTATION 

Bowel sounds are heard 

No bruits 

Respiratory system-

Trachea is central 
B/l air entry is present 
Normal respiratory movements 
Normal vesicular breath sounds

Cardiovascular system-
S1 and S2 heard no murmurs present 


CNS examination 
No focal neurological deficits 

PROVISIONAL DIAGNOSIS 

Acid peptic dyspepsia 

INVESTIGATIONS 



25/11/22




CBP

Serum calcium


Serum electrolytes



LFT




ULTRASOUND ABDOMEN



                        5/12/22

CBP



SERUM ELECTROLYTES


URINE EXAMINATION




                      16/12/22 
2D ECHO



ECG



  TREATMENT 


























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