34 year old male with Non ulcer dyspepsia with smoking and alcohol dependence

This is online E log book to discuss our patient’s de-identified health data shared 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. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .

I’ve 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.

Chief complaints: 

Patient complaints of 

Indigestion  and burning sensation in epigastric region since 2 and half year 

B/L loin pain since 1year 

Cough since 4 months

HOPI:

Patient was apparently asymptomatic  2 and half years back then he developed indigestion and epigastric pain

And abdominal bloating which was not associated with loose stools or vomitings which was relieved on taking medication for some time then the symptoms appear again 

Pt c/o b/l loin pain non radiating type  associated with intermittent burning micturition since 3-4 months 

Past history: 

H/o renal calculi 5 years back 

Not a k/c/o DM, HTN, asthma , epilepsy, thyroid,CAD , TB

Personal history:

Diet: mixed 

Appetite: normal 

Sleep: adequate 

Bowel and bladder habits : regular 

Addictions: 

Smoking since 7 years 

2-3 cigars per day 

Allergies: 

He is allergic to brinjal, egg and meat since 1 and half year 

Family history: 

Insignificant 

General examination 

Patient is conscious coherent cooperative 

Well oriented to time place and person 

Moderately built and nourished 

Vitals; 

Temp: afebrile 

Pulse rate: 90bpm

Respiratory rate: 22

BP: 110/80

SpO2:98

Pallor, icterus, cyanosis, clubbing, lymphadenopathy, are absent 

Systemic examination 

CVS : s1 s2 heard no murmurs present 

Respiratory: bilateral normal vesicular breath sounds are present 

CNS: no neurological deficits are present 

Abdominal examination:

Inspection: 

Abdominal moves equally with respiration 

No scars , sinuses, engorged veins 

Umbilicus inverted 

No visible peristalsis 

Palpitation:

Soft non-tender 

No guarding , rigidity, rebound tenderness 

no hepatomegaly or splenomegaly 

Percussion: 

No fluid thrill 

No shifting dullness 

Auscultation: 

Bowel sounds heard 

Investigations: 

Hemogram: 

Chest X-ray :

USG abdomen : 

ECG : 

Provisional diagnosis: 

Non ulcer dyspepsia with smoking and alcohol dependence 

Treatment: 

1) tab pan 40mg po OD 

2) tab mvt po OD 

Discharge summary: