55 year old male with acute gastritis
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Chief complaint:
A 55 year old male came to OPD complaints of left side chest pain since 15 days
Right chest pain which is radiating to back and also complaints of body pains, headache, sleeplessness.
History of present illness:
Patient was apparently asymptomatic 15 days back then he developed left chest pain and right chest pain which is radiating to back.
Dry eyes,dry mouth
No h/o fever, nausea, vomiting
Patient went to nalgonda govt hospital intially with same complaints and got basic investigations done now he came to casualty for further management
Past history:
No h/o diabetes mellitus, asthma,hypertension, epilepsy, tuberculosis, hepatitis and cvs problems
Personal history:
Diet- mixed with normal appetite
Bowel and bladder movements - normal
Sleep- inadequate
Alocholic since 20 years
No known relevant drug history
Family history: no known relevant family history
General examination:
Patient is conscious, coherent, cooperative and we'll oriented to time,place and person
Moderately built and nourished
No features indicating the presence of:
Pallor, icterus, cyanosis, clubbing of fingers,edema, lymphadenopathy.
Vitals:
Temperature: Afebrile
Pulse rate: 72 beats per min
Blood pressure: 130/80mmhg
Respiratory rate: 18 cycles per min
Systemic examination:
CVS- S1and S2 heart sounds heard and no cardiac murmurs
No thrills
Abdomen:
Inspection:
Shape of the abdomen: obese, with no distension.
Umbilicus: inverted
No dilated veins
No visible pulsation
No localised swellings
No scars are seen
Palpation:
No local rise of temperature
No tenderness
No splenomegaly
No hepatomegaly
Percussion:
Liver span- 12cm
Fluid thrills- absent
Shifting dullness - absent
Puddle sign- absent
Auscultation:
Bowel sounds present
No bruits
Respiratory examination:
Normal vesicular breath sounds heard
Provisional diagnosis:
Alocholic gastritis
Investigations:
Hemogram-
Hb-14.9gm/dl
Total leucocyte count- 8300 cells/cumm
Platelets - 4.4lakhs/cum
Treatment:
Tab: pan-40mg/po/od
Tab: ecosprin 75mg po/od
Tab: atrovas 10mg po/od
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