55 year old male with acute gastritis

​This is an 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 patient's clinical problems with collective current best evidence based inputs.


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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