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