A 60 year old male patient with indigestion

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Chief Complaints:

Patient complaints of indigestion since 4months

History of Present Illness:

Patient was apparently asymptomatic 4months ago he then noticed indigestion 

H/o B/l knee joint pain since 1 year

H/o chest pain (on right and left side) non radiating, burning,spasmodic type of pain since 3 months

No h/o excessive sweating, palpitations,pedal edema, giddiness

H/o abdominal distension and bloated sensation after eating food

No h/o headache, vomitings, loose stools and pain abdomen

History of Past illness:

H/o Diabetes since 3 1/2 year

No h/o hypertension, TB,asthma,CAD

Personal History:

Married

Daily wage labour

Appetite-normal

Diet-Mixed

Bowel movement-Normal

Micturition-normal

Habits-smoking since 25years and now stopped

Family History:

No members of the family the similar condition

General Examination:

Vitals:

Temp:96.8

Respiratory rate:18cycles/min

Pulse: 90bpm

Blood pressure:130/80mmhg

Sp O2 -97%

GRBS-287mg/dl

Systemic Examination:

Cardiovascular Examination:

Thrills:no

Cardiac sounds:S1,S2 heard

Cardiac murmurs:no

Respiratory system:

Dyspnea: yes

Wheeze:no

Position of trachea: central

Breath sounds: vesicular

Adventitious sounds:no

Abdomen

Shape of abdomen: scaphoid

Tenderness:no

Palpable mass:no

Henias orifices: normal

Free fluid:no

Bruits:no

 

Liver: not palpable

Spleen:not  palpable

Bowel sound:no

Central Nervous system:

 Pt is conscious

Speech: normal 

Signs of meningitis: 

         Neck stiffness:no

         Kerning sign:no

Cranial nerves:  normal

Motor and sensory system: normal

Provisional Diagnosis:

Peptic ulcer

Investigation:

HEMOGRAM:-

Hb-13.4 g/dl

TLC-

Lymphocytes-41%

MCV-74.3fl

MCH-24.5pg

Platelets-2.2lakhs/cumm

RBC-5.45 million/cumm

Albumin-Trace

Sugar-++++

Pus cells-2-3/HPF

Epithelial cells- 3-4/HPF

Blood urea-23mg/dl

Serum creatinine-1.0mg/dl

LFT:-

TB-1.05mg/dl

DB-0.25mg/dl

AST-14

ALT-15

Alkaline phosphatase-22l

Total protein-6.8g/dl

Albumin-3.89g/dl

A/G ratio-1.3

SEROLOGY:-

HbsAg-negative

HSV-negative

HIV-negative

Treatment:

Tab PAN 40mg PO/OD

Tab MVT PO/OD