Prefinals general medicine case

This is an online e log book to discuss our patient's de-identified health data after taking his/her/guardian's  signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. 

CASE : 

Date of admission- December 17, 2021


A 29 yes 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. Does he diagnosed to have ( ? Gastritis ).

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




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