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:
     
     

       

          


        


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